Background: Analogous to the Bispectral Index ® (BIS ®) monitor, the auditory evoked potential mo... more Background: Analogous to the Bispectral Index ® (BIS ®) monitor, the auditory evoked potential monitor provides an electroencephalographic-derived index (AAI), which is alleged to correlate with the central nervous system depressant effects of anesthetic drugs. This clinical study was designed to test the hypothesis that intraoperative cerebral monitoring guided by either the BIS or the AAI value would facilitate recovery from general anesthesia compared with standard clinical monitoring practices alone in the ambulatory setting. Methods: Sixty consenting outpatients undergoing gynecologic laparoscopic surgery were randomly assigned to one of three study groups: (1) control (standard practice), (2) BIS guided, or (3) AAI guided. Anesthesia was induced with 1.5-2.5 mg/kg propofol and 1-1.5 g/kg fentanyl given intravenously. Desflurane, 3%, in combination with 60% nitrous oxide in oxygen was administered for maintenance of general anesthesia. In the control group, the inspired desflurane concentration was varied based on standard clinical signs. In the BIS-and AAI-guided groups, the inspired desflurane concentrations were titrated to maintain BIS and AAI values in targeted ranges of 50-60 and 15-25, respectively. BIS and AAI values, hemodynamic variables, and the end-tidal desflurane concentration were recorded at 5-min intervals during the maintenance period. The emergence times and recovery times to achieve specific clinical endpoints were recorded at 1-to 10-min intervals. The White fast-track and modified Aldrete recovery scores were assessed on arrival in the PACU, and the quality of recovery score was evaluated at the time of discharge home. Results: A positive correlation was found between the AAI and BIS values during the maintenance period. The average BIS and AAI values (mean ؎ SD) during the maintenance period were significantly lower in the control group (BIS, 41 ؎ 10; AAI, 11 ؎ 6) compared with the BIS-guided (BIS, 57 ؎ 14; AAI, 18 ؎ 11) and AAI-guided (BIS, 55 ؎ 12; AAI, 20 ؎ 10) groups. The endtidal desflurane concentration was significantly reduced in the BIS-guided (2.7 ؎ 0.9%) and AAI-guided (2.6 ؎ 0.9%) groups compared with the control group (3.6 ؎ 1.5%). The awakening (eye-opening) and discharge times were significantly shorter in the BIS-guided (7 ؎ 3 and 132 ؎ 39 min, respectively) and AAI-guided (6 ؎ 2 and 128 ؎ 39 min, respectively) groups compared with the control group (9 ؎ 4 and 195 ؎ 57 min, respectively). More importantly, the median [range] quality of recovery scores was significantly higher in the BIS-guided (18 [17-18]) and AAI-guided (18 [17-18]) groups when compared with the control group (16 [10-18]). Conclusion: Compared with standard anesthesia monitoring practice, adjunctive use of auditory evoked potential and BIS monitoring can improve titration of desflurane during general anesthesia, leading to an improved recovery profile after ambulatory surgery.
Dolasetron (12.5 mg IV) is effective in both preventing and treating postoperative nausea and vom... more Dolasetron (12.5 mg IV) is effective in both preventing and treating postoperative nausea and vomiting (PONV) after ambulatory surgery. However, the optimal timing of dolasetron administration and its effect on the patient's quality of life after discharge have not been established. One-hundred-five healthy, consenting women undergoing gynecologic laparoscopic procedures with a standardized general anesthetic technique were enrolled in this randomized, double-blinded study. Group 1 received dolasetron 12.5 mg IV 10-15 min before the induction of anesthesia; Group 2 received dolasetron 12.5 mg IV at the end of the laparoscopy (79 +/- 48 min later than Group 1); and Group 3 received dolasetron 12.5 mg IV at the end of anesthesia (93 +/- 52 min later than Group 1). The incidence of PONV, complete responses (defined as no emetic episodes and no rescue medication within the 24-h period after anesthesia), recovery profiles, and patient satisfaction were recorded. In the postanesthesia care unit and during the 24-h follow-up period, the incidence of nausea and vomiting, as well as the need for rescue antiemetics, did not differ significantly among the three groups. The percentages of patients with complete responses to the study drug within the first postoperative 24 h were also similar in all three groups (55%, 59%, and 52% for Groups 1, 2, and 3, respectively). The early and intermediate recovery profiles, including resumption of a normal diet and patient satisfaction with the control of PONV, were not different among the three study groups. Dolasetron 12.5 mg IV administered before the induction of anesthesia is as effective as dolasetron given at the end of laparoscopy or at the end of anesthesia in preventing PONV after outpatient laparoscopy. The timing of dolasetron administration appears to have little effect on its efficacy when administered as a prophylactic antiemetic in the ambulatory setting.
Compared to propofol, maintenance of anesthesia with desflurane provided significantly better int... more Compared to propofol, maintenance of anesthesia with desflurane provided significantly better intraoperative conditions during office-based surgery. In addition, desflurane with routine antiemetic prophylaxis was associated with a faster early recovery and similar incidence of postoperative side effects.
We evaluated the cognitive recovery profiles in elderly patients after general anesthesia with de... more We evaluated the cognitive recovery profiles in elderly patients after general anesthesia with desflurane or sevoflurane. After IRB approval, 70 ASA physical status I-III consenting elderly patients (> or =65 yr old) undergoing total knee or hip replacement procedures were randomly assigned to one of two general anesthetic groups. Propofol and fentanyl were administered for induction of anesthesia, followed by either desflurane 2%-4% or sevoflurane 1%-1.5% with nitrous oxide 65% in oxygen. The desflurane (2.5 +/- 0.6 MAC. h) and sevoflurane (2.7 +/- 0.5 MAC. h) concentrations were adjusted to maintain comparable depths of hypnosis using the electroencephalogram bispectral index monitor. The Mini-Mental State (MMS) test was used to assess cognitive function preoperatively and postoperatively at 1, 3, 6, and 24-h intervals. The use of desflurane was associated with a more rapid emergence from anesthesia (6.3 +/- 2.4 min versus 8.0 +/- 2.8 min) and a shorter length of stay in the postanesthesia care unit (213 +/- 66 min versus 241 +/- 87 min). However, there were no significant differences between the Desflurane and the Sevoflurane groups when the MMS scores were compared preoperatively, and postoperatively at 1, 3, 6, and 24 h. Compared with the preoperative (baseline) MMS scores, the values were significantly decreased at 1 h postoperatively (27.8 +/- 1.7 versus 29.5 +/- 0.5 in the Desflurane group, and 27.4 +/- 1.7 versus 29.2 +/- 1.0 in the Sevoflurane group, respectively). However, the MMS scores returned to preoperative baseline levels within 6 h after surgery. At 1 h and 3 h after surgery, 51% and 11% (versus 57% and 9%) of patients in the Desflurane (versus Sevoflurane) Group experienced cognitive impairment. In conclusion, desflurane is associated with a faster early recovery than sevoflurane after general anesthesia in elderly patients. However, recovery of cognitive function was similar after desflurane and sevoflurane-based anesthesia. Desflurane was associated with a faster early recovery than sevoflurane after general anesthesia in elderly patients. However, recovery of cognitive function was similar with both volatile anesthetics.
Study Objective: To evaluate the effect of different maintenance boluses of a short-acting nondep... more Study Objective: To evaluate the effect of different maintenance boluses of a short-acting nondepolarizing neuromuscular blocking drug on its spontaneous recovery profile during anesthesia. Design: Prospective, randomized, double-blind, dose-ranging study. Setting: University-based medical center. Patients: 69 ASA physical status I and II consenting adult outpatients undergoing general anesthesia with an anticipated duration of at least 2 hours. Interventions: Patients were randomized to one of three study groups. Following induction of anesthesia with propofol and fentanyl, rapacuronium 1.5 mg ⅐ kg-1 intravenously (IV), was administered to facilitate tracheal intubation. Anesthesia was maintained with desflurane 4% end-tidal in combination with nitrous oxide 67% in oxygen. When the first twitch (T 1) in the train-of-four (TOF) returned to 25% of its baseline value, a maintenance dose of rapacuronium 0.25 mg ⅐ kg-1 IV (Group 1), 0.5 mg ⅐ kg-1 IV (Group 2), or 0.75 mg ⅐ kg-1 IV (Group 3) was administered. The time course of neuromuscular block was monitored at the wrist using standard electromyography. Measurements and Main Results: The times for recovery of the T 1 to 25% of the baseline value following different maintenance doses of rapacuronium were only 6.3 Ϯ 2.2, 7.5 Ϯ 2.3, and 9.6 Ϯ 2.5 minutes, in Groups 1, 2 and 3, respectively. However, the times for the TOF ratio to return to 0.7 were 44 Ϯ 15, 53 Ϯ 20, and 66 Ϯ 30 minutes in Groups 1, 2, and 3, respectively. Although recovery times were significantly longer after rapacuronium 0.75 mg ⅐ kg-1 IV (Group 3), there were no significant differences in any of the recovery variables between Groups 1 and 2. Conclusions: Spontaneous recovery of the T 1 to 25% of the baseline value occurred 6 to 10 minutes after a maintenance bolus dose of rapacuronium 0.25 to 0.75 mg ⅐ kg-1 IV. However, recovery to a TOF Ͼ0.7 required 44 to 66 minutes during desflurane anesthesia.
Background: Office-based surgery is becoming increasingly popular because of its cost-saving pote... more Background: Office-based surgery is becoming increasingly popular because of its cost-saving potential. Both propofol and sevoflurane are commonly used in the ambulatory setting because of their favorable recovery profiles. This clinical investigation was designed to compare the clinical effects, recovery characteristics, and cost-effectiveness of propofol and swoflurane when used alone or in combination for office-based anesthesia. Methods: One hundred four outpatients undergoing superficial surgical procedures at an office-based surgical center were
Intraoperative extracorporeal membrane oxygenation (ECMO) support, both venoarterial and venoveno... more Intraoperative extracorporeal membrane oxygenation (ECMO) support, both venoarterial and venovenous (VV), have been used sparingly and with limited success in the setting of liver transplantation. Here, we report the successful use of VV-ECMO in the resuscitation and pulmonary bridging support after severe systemic inflammatory response in a combined liver and kidney transplant recipient who suffered primary nonfunction of both allografts. Where conventional ventilator maneuvers may prove ineffective, the implementation of VV-ECMO should be considered as a therapeutic option in limited, short-lived acute pulmonary injury.
β-blockers like labetalol and esmolol have been successfully used for controlling acute autonomic... more β-blockers like labetalol and esmolol have been successfully used for controlling acute autonomic responses during surgery. Objective: To compare the intraoperative use of labetalol and esmolol to fentanyl for maintaining hemodynamic stability during laparoscopic surgery and assess their effects on recovery profiles. Methods: 75 patients were randomly assigned to receive one of three different adjunctive treatments regimens. Immediately prior to induction of anesthesia, 1 mL of the unlabeled study medication (fentanyl [50µg/mL], or labetalol [5mg/mL], or esmolol [10 mg/mL]) was administered. A second 1mL dose of the same study medication was administered immediately before skin incision and subsequently as needed ['rescue'] during the surgical procedure to maintain heart rate (HR) and mean arterial pressure within 15% of the pre-induction baseline values. Results: The labetalol and esmolol groups had similar intraoperative HR and MAP values compared to the fentanyl group (p=0.4 and p=0.1 respectively). Fewer patients in the labetalol group required intraoperative rescue medications compared to the esmolol and fentanyl groups (p=0.0003). There were no significant differences in the requirement for parenteral opioid medication in the early postoperative period among the three groups. Of the post-discharge recovery outcomes studied, only incidence of 'low appetite' differed among the three groups, favoring the labetalol group over the fentanyl group (p=0.05). Labetalol was also less costly than both esmolol and fentanyl. Conclusion: Labetalol and esmolol were found to be comparable to fentanyl for maintaining hemodynamic stability during laparoscopic surgery. However, labetalol required less intraoperative rescue medication and had less adverse effect on appetite in the post-discharge period.
Folate deficiency and megaloblastic anemia occur in chronic renal failure. However, the possible ... more Folate deficiency and megaloblastic anemia occur in chronic renal failure. However, the possible role of intestinal malabsorption as a cause of the reported deficiency has not been investigated. Therefore, we examined the intestinal absorption of 5-methyltetrahydrofolate in rats made uremic by subtotal nephrectomy using in vivo perfusion technique and in vitro everted sac technique. The results were compared with those obtained in a group of sham-operated rats with normal renal function. The amount of 5-methyltetrahydrofolate absorbed in vivo was significantly lower in the uremic animals as compared to the control group. In contrast, no significant difference was found in the absorption of 5-methyltetrahydrofolate in vitro in the two groups. To mimic the uremic environment, the in vitro studies were repeated using jejunal sacs from normal animals filled with either buffer solution, or sera from uremic patients before and after dialysis. Their results showed a marked suppression of 5...
Study Objective: To evaluate the effect of different maintenance boluses of a short-acting nondep... more Study Objective: To evaluate the effect of different maintenance boluses of a short-acting nondepolarizing neuromuscular blocking drug on its spontaneous recovery profile during anesthesia. Design: Prospective, randomized, double-blind, dose-ranging study. Setting: University-based medical center. Patients: 69 ASA physical status I and II consenting adult outpatients undergoing general anesthesia with an anticipated duration of at least 2 hours. Interventions: Patients were randomized to one of three study groups. Following induction of anesthesia with propofol and fentanyl, rapacuronium 1.5 mg ⅐ kg-1 intravenously (IV), was administered to facilitate tracheal intubation. Anesthesia was maintained with desflurane 4% end-tidal in combination with nitrous oxide 67% in oxygen. When the first twitch (T 1) in the train-of-four (TOF) returned to 25% of its baseline value, a maintenance dose of rapacuronium 0.25 mg ⅐ kg-1 IV (Group 1), 0.5 mg ⅐ kg-1 IV (Group 2), or 0.75 mg ⅐ kg-1 IV (Group 3) was administered. The time course of neuromuscular block was monitored at the wrist using standard electromyography. Measurements and Main Results: The times for recovery of the T 1 to 25% of the baseline value following different maintenance doses of rapacuronium were only 6.3 Ϯ 2.2, 7.5 Ϯ 2.3, and 9.6 Ϯ 2.5 minutes, in Groups 1, 2 and 3, respectively. However, the times for the TOF ratio to return to 0.7 were 44 Ϯ 15, 53 Ϯ 20, and 66 Ϯ 30 minutes in Groups 1, 2, and 3, respectively. Although recovery times were significantly longer after rapacuronium 0.75 mg ⅐ kg-1 IV (Group 3), there were no significant differences in any of the recovery variables between Groups 1 and 2. Conclusions: Spontaneous recovery of the T 1 to 25% of the baseline value occurred 6 to 10 minutes after a maintenance bolus dose of rapacuronium 0.25 to 0.75 mg ⅐ kg-1 IV. However, recovery to a TOF Ͼ0.7 required 44 to 66 minutes during desflurane anesthesia.
Background Office-based surgery has become increasingly popular because of its cost-saving potent... more Background Office-based surgery has become increasingly popular because of its cost-saving potential. However, the occurrence of postoperative nausea and vomiting (PONV) can delay patient discharge. Prophylaxis using a combination of antiemetic drugs has been suggested as an effective strategy for minimizing PONV. The authors designed this randomized, double-blinded, placebo-controlled study to assess the efficacy of ondansetron and dolasetron when administered in combination with droperidol and dexamethasone for routine antiemetic prophylaxis against PONV in the office-based surgery setting. Methods Following institutional review board approval, 135 consenting outpatients with American Society of Anesthesiologists physical status I-III who were undergoing superficial surgical procedures lasting 20-40 min were randomly assigned to one of three antiemetic treatment groups. Propofol was administered for induction of anesthesia, followed by 2-4% desflurane with 67% nitrous oxide in oxy...
Background Analogous to the Bispectral Index (BIS) monitor, the auditory evoked potential monitor... more Background Analogous to the Bispectral Index (BIS) monitor, the auditory evoked potential monitor provides an electroencephalographic-derived index (AAI), which is alleged to correlate with the central nervous system depressant effects of anesthetic drugs. This clinical study was designed to test the hypothesis that intraoperative cerebral monitoring guided by either the BIS or the AAI value would facilitate recovery from general anesthesia compared with standard clinical monitoring practices alone in the ambulatory setting. Methods Sixty consenting outpatients undergoing gynecologic laparoscopic surgery were randomly assigned to one of three study groups: (1) control (standard practice), (2) BIS guided, or (3) AAI guided. Anesthesia was induced with 1.5-2.5 mg/kg propofol and 1-1.5 microg/kg fentanyl given intravenously. Desflurane, 3%, in combination with 60% nitrous oxide in oxygen was administered for maintenance of general anesthesia. In the control group, the inspired desflura...
Use of acupressure as part of a multimodal prophylactic antiemetic regimen Financial support: The... more Use of acupressure as part of a multimodal prophylactic antiemetic regimen Financial support: The active and sham Pressure Right® acupressure devices were provided by Therapeutics: 101 Inc. Dr. White receives support from the White Mountain Institute, a private non-for-profit education and research foundation. .
Background: Analogous to the Bispectral Index ® (BIS ®) monitor, the auditory evoked potential mo... more Background: Analogous to the Bispectral Index ® (BIS ®) monitor, the auditory evoked potential monitor provides an electroencephalographic-derived index (AAI), which is alleged to correlate with the central nervous system depressant effects of anesthetic drugs. This clinical study was designed to test the hypothesis that intraoperative cerebral monitoring guided by either the BIS or the AAI value would facilitate recovery from general anesthesia compared with standard clinical monitoring practices alone in the ambulatory setting. Methods: Sixty consenting outpatients undergoing gynecologic laparoscopic surgery were randomly assigned to one of three study groups: (1) control (standard practice), (2) BIS guided, or (3) AAI guided. Anesthesia was induced with 1.5-2.5 mg/kg propofol and 1-1.5 g/kg fentanyl given intravenously. Desflurane, 3%, in combination with 60% nitrous oxide in oxygen was administered for maintenance of general anesthesia. In the control group, the inspired desflurane concentration was varied based on standard clinical signs. In the BIS-and AAI-guided groups, the inspired desflurane concentrations were titrated to maintain BIS and AAI values in targeted ranges of 50-60 and 15-25, respectively. BIS and AAI values, hemodynamic variables, and the end-tidal desflurane concentration were recorded at 5-min intervals during the maintenance period. The emergence times and recovery times to achieve specific clinical endpoints were recorded at 1-to 10-min intervals. The White fast-track and modified Aldrete recovery scores were assessed on arrival in the PACU, and the quality of recovery score was evaluated at the time of discharge home. Results: A positive correlation was found between the AAI and BIS values during the maintenance period. The average BIS and AAI values (mean ؎ SD) during the maintenance period were significantly lower in the control group (BIS, 41 ؎ 10; AAI, 11 ؎ 6) compared with the BIS-guided (BIS, 57 ؎ 14; AAI, 18 ؎ 11) and AAI-guided (BIS, 55 ؎ 12; AAI, 20 ؎ 10) groups. The endtidal desflurane concentration was significantly reduced in the BIS-guided (2.7 ؎ 0.9%) and AAI-guided (2.6 ؎ 0.9%) groups compared with the control group (3.6 ؎ 1.5%). The awakening (eye-opening) and discharge times were significantly shorter in the BIS-guided (7 ؎ 3 and 132 ؎ 39 min, respectively) and AAI-guided (6 ؎ 2 and 128 ؎ 39 min, respectively) groups compared with the control group (9 ؎ 4 and 195 ؎ 57 min, respectively). More importantly, the median [range] quality of recovery scores was significantly higher in the BIS-guided (18 [17-18]) and AAI-guided (18 [17-18]) groups when compared with the control group (16 [10-18]). Conclusion: Compared with standard anesthesia monitoring practice, adjunctive use of auditory evoked potential and BIS monitoring can improve titration of desflurane during general anesthesia, leading to an improved recovery profile after ambulatory surgery.
Dolasetron (12.5 mg IV) is effective in both preventing and treating postoperative nausea and vom... more Dolasetron (12.5 mg IV) is effective in both preventing and treating postoperative nausea and vomiting (PONV) after ambulatory surgery. However, the optimal timing of dolasetron administration and its effect on the patient's quality of life after discharge have not been established. One-hundred-five healthy, consenting women undergoing gynecologic laparoscopic procedures with a standardized general anesthetic technique were enrolled in this randomized, double-blinded study. Group 1 received dolasetron 12.5 mg IV 10-15 min before the induction of anesthesia; Group 2 received dolasetron 12.5 mg IV at the end of the laparoscopy (79 +/- 48 min later than Group 1); and Group 3 received dolasetron 12.5 mg IV at the end of anesthesia (93 +/- 52 min later than Group 1). The incidence of PONV, complete responses (defined as no emetic episodes and no rescue medication within the 24-h period after anesthesia), recovery profiles, and patient satisfaction were recorded. In the postanesthesia care unit and during the 24-h follow-up period, the incidence of nausea and vomiting, as well as the need for rescue antiemetics, did not differ significantly among the three groups. The percentages of patients with complete responses to the study drug within the first postoperative 24 h were also similar in all three groups (55%, 59%, and 52% for Groups 1, 2, and 3, respectively). The early and intermediate recovery profiles, including resumption of a normal diet and patient satisfaction with the control of PONV, were not different among the three study groups. Dolasetron 12.5 mg IV administered before the induction of anesthesia is as effective as dolasetron given at the end of laparoscopy or at the end of anesthesia in preventing PONV after outpatient laparoscopy. The timing of dolasetron administration appears to have little effect on its efficacy when administered as a prophylactic antiemetic in the ambulatory setting.
Compared to propofol, maintenance of anesthesia with desflurane provided significantly better int... more Compared to propofol, maintenance of anesthesia with desflurane provided significantly better intraoperative conditions during office-based surgery. In addition, desflurane with routine antiemetic prophylaxis was associated with a faster early recovery and similar incidence of postoperative side effects.
We evaluated the cognitive recovery profiles in elderly patients after general anesthesia with de... more We evaluated the cognitive recovery profiles in elderly patients after general anesthesia with desflurane or sevoflurane. After IRB approval, 70 ASA physical status I-III consenting elderly patients (> or =65 yr old) undergoing total knee or hip replacement procedures were randomly assigned to one of two general anesthetic groups. Propofol and fentanyl were administered for induction of anesthesia, followed by either desflurane 2%-4% or sevoflurane 1%-1.5% with nitrous oxide 65% in oxygen. The desflurane (2.5 +/- 0.6 MAC. h) and sevoflurane (2.7 +/- 0.5 MAC. h) concentrations were adjusted to maintain comparable depths of hypnosis using the electroencephalogram bispectral index monitor. The Mini-Mental State (MMS) test was used to assess cognitive function preoperatively and postoperatively at 1, 3, 6, and 24-h intervals. The use of desflurane was associated with a more rapid emergence from anesthesia (6.3 +/- 2.4 min versus 8.0 +/- 2.8 min) and a shorter length of stay in the postanesthesia care unit (213 +/- 66 min versus 241 +/- 87 min). However, there were no significant differences between the Desflurane and the Sevoflurane groups when the MMS scores were compared preoperatively, and postoperatively at 1, 3, 6, and 24 h. Compared with the preoperative (baseline) MMS scores, the values were significantly decreased at 1 h postoperatively (27.8 +/- 1.7 versus 29.5 +/- 0.5 in the Desflurane group, and 27.4 +/- 1.7 versus 29.2 +/- 1.0 in the Sevoflurane group, respectively). However, the MMS scores returned to preoperative baseline levels within 6 h after surgery. At 1 h and 3 h after surgery, 51% and 11% (versus 57% and 9%) of patients in the Desflurane (versus Sevoflurane) Group experienced cognitive impairment. In conclusion, desflurane is associated with a faster early recovery than sevoflurane after general anesthesia in elderly patients. However, recovery of cognitive function was similar after desflurane and sevoflurane-based anesthesia. Desflurane was associated with a faster early recovery than sevoflurane after general anesthesia in elderly patients. However, recovery of cognitive function was similar with both volatile anesthetics.
Study Objective: To evaluate the effect of different maintenance boluses of a short-acting nondep... more Study Objective: To evaluate the effect of different maintenance boluses of a short-acting nondepolarizing neuromuscular blocking drug on its spontaneous recovery profile during anesthesia. Design: Prospective, randomized, double-blind, dose-ranging study. Setting: University-based medical center. Patients: 69 ASA physical status I and II consenting adult outpatients undergoing general anesthesia with an anticipated duration of at least 2 hours. Interventions: Patients were randomized to one of three study groups. Following induction of anesthesia with propofol and fentanyl, rapacuronium 1.5 mg ⅐ kg-1 intravenously (IV), was administered to facilitate tracheal intubation. Anesthesia was maintained with desflurane 4% end-tidal in combination with nitrous oxide 67% in oxygen. When the first twitch (T 1) in the train-of-four (TOF) returned to 25% of its baseline value, a maintenance dose of rapacuronium 0.25 mg ⅐ kg-1 IV (Group 1), 0.5 mg ⅐ kg-1 IV (Group 2), or 0.75 mg ⅐ kg-1 IV (Group 3) was administered. The time course of neuromuscular block was monitored at the wrist using standard electromyography. Measurements and Main Results: The times for recovery of the T 1 to 25% of the baseline value following different maintenance doses of rapacuronium were only 6.3 Ϯ 2.2, 7.5 Ϯ 2.3, and 9.6 Ϯ 2.5 minutes, in Groups 1, 2 and 3, respectively. However, the times for the TOF ratio to return to 0.7 were 44 Ϯ 15, 53 Ϯ 20, and 66 Ϯ 30 minutes in Groups 1, 2, and 3, respectively. Although recovery times were significantly longer after rapacuronium 0.75 mg ⅐ kg-1 IV (Group 3), there were no significant differences in any of the recovery variables between Groups 1 and 2. Conclusions: Spontaneous recovery of the T 1 to 25% of the baseline value occurred 6 to 10 minutes after a maintenance bolus dose of rapacuronium 0.25 to 0.75 mg ⅐ kg-1 IV. However, recovery to a TOF Ͼ0.7 required 44 to 66 minutes during desflurane anesthesia.
Background: Office-based surgery is becoming increasingly popular because of its cost-saving pote... more Background: Office-based surgery is becoming increasingly popular because of its cost-saving potential. Both propofol and sevoflurane are commonly used in the ambulatory setting because of their favorable recovery profiles. This clinical investigation was designed to compare the clinical effects, recovery characteristics, and cost-effectiveness of propofol and swoflurane when used alone or in combination for office-based anesthesia. Methods: One hundred four outpatients undergoing superficial surgical procedures at an office-based surgical center were
Intraoperative extracorporeal membrane oxygenation (ECMO) support, both venoarterial and venoveno... more Intraoperative extracorporeal membrane oxygenation (ECMO) support, both venoarterial and venovenous (VV), have been used sparingly and with limited success in the setting of liver transplantation. Here, we report the successful use of VV-ECMO in the resuscitation and pulmonary bridging support after severe systemic inflammatory response in a combined liver and kidney transplant recipient who suffered primary nonfunction of both allografts. Where conventional ventilator maneuvers may prove ineffective, the implementation of VV-ECMO should be considered as a therapeutic option in limited, short-lived acute pulmonary injury.
β-blockers like labetalol and esmolol have been successfully used for controlling acute autonomic... more β-blockers like labetalol and esmolol have been successfully used for controlling acute autonomic responses during surgery. Objective: To compare the intraoperative use of labetalol and esmolol to fentanyl for maintaining hemodynamic stability during laparoscopic surgery and assess their effects on recovery profiles. Methods: 75 patients were randomly assigned to receive one of three different adjunctive treatments regimens. Immediately prior to induction of anesthesia, 1 mL of the unlabeled study medication (fentanyl [50µg/mL], or labetalol [5mg/mL], or esmolol [10 mg/mL]) was administered. A second 1mL dose of the same study medication was administered immediately before skin incision and subsequently as needed ['rescue'] during the surgical procedure to maintain heart rate (HR) and mean arterial pressure within 15% of the pre-induction baseline values. Results: The labetalol and esmolol groups had similar intraoperative HR and MAP values compared to the fentanyl group (p=0.4 and p=0.1 respectively). Fewer patients in the labetalol group required intraoperative rescue medications compared to the esmolol and fentanyl groups (p=0.0003). There were no significant differences in the requirement for parenteral opioid medication in the early postoperative period among the three groups. Of the post-discharge recovery outcomes studied, only incidence of 'low appetite' differed among the three groups, favoring the labetalol group over the fentanyl group (p=0.05). Labetalol was also less costly than both esmolol and fentanyl. Conclusion: Labetalol and esmolol were found to be comparable to fentanyl for maintaining hemodynamic stability during laparoscopic surgery. However, labetalol required less intraoperative rescue medication and had less adverse effect on appetite in the post-discharge period.
Folate deficiency and megaloblastic anemia occur in chronic renal failure. However, the possible ... more Folate deficiency and megaloblastic anemia occur in chronic renal failure. However, the possible role of intestinal malabsorption as a cause of the reported deficiency has not been investigated. Therefore, we examined the intestinal absorption of 5-methyltetrahydrofolate in rats made uremic by subtotal nephrectomy using in vivo perfusion technique and in vitro everted sac technique. The results were compared with those obtained in a group of sham-operated rats with normal renal function. The amount of 5-methyltetrahydrofolate absorbed in vivo was significantly lower in the uremic animals as compared to the control group. In contrast, no significant difference was found in the absorption of 5-methyltetrahydrofolate in vitro in the two groups. To mimic the uremic environment, the in vitro studies were repeated using jejunal sacs from normal animals filled with either buffer solution, or sera from uremic patients before and after dialysis. Their results showed a marked suppression of 5...
Study Objective: To evaluate the effect of different maintenance boluses of a short-acting nondep... more Study Objective: To evaluate the effect of different maintenance boluses of a short-acting nondepolarizing neuromuscular blocking drug on its spontaneous recovery profile during anesthesia. Design: Prospective, randomized, double-blind, dose-ranging study. Setting: University-based medical center. Patients: 69 ASA physical status I and II consenting adult outpatients undergoing general anesthesia with an anticipated duration of at least 2 hours. Interventions: Patients were randomized to one of three study groups. Following induction of anesthesia with propofol and fentanyl, rapacuronium 1.5 mg ⅐ kg-1 intravenously (IV), was administered to facilitate tracheal intubation. Anesthesia was maintained with desflurane 4% end-tidal in combination with nitrous oxide 67% in oxygen. When the first twitch (T 1) in the train-of-four (TOF) returned to 25% of its baseline value, a maintenance dose of rapacuronium 0.25 mg ⅐ kg-1 IV (Group 1), 0.5 mg ⅐ kg-1 IV (Group 2), or 0.75 mg ⅐ kg-1 IV (Group 3) was administered. The time course of neuromuscular block was monitored at the wrist using standard electromyography. Measurements and Main Results: The times for recovery of the T 1 to 25% of the baseline value following different maintenance doses of rapacuronium were only 6.3 Ϯ 2.2, 7.5 Ϯ 2.3, and 9.6 Ϯ 2.5 minutes, in Groups 1, 2 and 3, respectively. However, the times for the TOF ratio to return to 0.7 were 44 Ϯ 15, 53 Ϯ 20, and 66 Ϯ 30 minutes in Groups 1, 2, and 3, respectively. Although recovery times were significantly longer after rapacuronium 0.75 mg ⅐ kg-1 IV (Group 3), there were no significant differences in any of the recovery variables between Groups 1 and 2. Conclusions: Spontaneous recovery of the T 1 to 25% of the baseline value occurred 6 to 10 minutes after a maintenance bolus dose of rapacuronium 0.25 to 0.75 mg ⅐ kg-1 IV. However, recovery to a TOF Ͼ0.7 required 44 to 66 minutes during desflurane anesthesia.
Background Office-based surgery has become increasingly popular because of its cost-saving potent... more Background Office-based surgery has become increasingly popular because of its cost-saving potential. However, the occurrence of postoperative nausea and vomiting (PONV) can delay patient discharge. Prophylaxis using a combination of antiemetic drugs has been suggested as an effective strategy for minimizing PONV. The authors designed this randomized, double-blinded, placebo-controlled study to assess the efficacy of ondansetron and dolasetron when administered in combination with droperidol and dexamethasone for routine antiemetic prophylaxis against PONV in the office-based surgery setting. Methods Following institutional review board approval, 135 consenting outpatients with American Society of Anesthesiologists physical status I-III who were undergoing superficial surgical procedures lasting 20-40 min were randomly assigned to one of three antiemetic treatment groups. Propofol was administered for induction of anesthesia, followed by 2-4% desflurane with 67% nitrous oxide in oxy...
Background Analogous to the Bispectral Index (BIS) monitor, the auditory evoked potential monitor... more Background Analogous to the Bispectral Index (BIS) monitor, the auditory evoked potential monitor provides an electroencephalographic-derived index (AAI), which is alleged to correlate with the central nervous system depressant effects of anesthetic drugs. This clinical study was designed to test the hypothesis that intraoperative cerebral monitoring guided by either the BIS or the AAI value would facilitate recovery from general anesthesia compared with standard clinical monitoring practices alone in the ambulatory setting. Methods Sixty consenting outpatients undergoing gynecologic laparoscopic surgery were randomly assigned to one of three study groups: (1) control (standard practice), (2) BIS guided, or (3) AAI guided. Anesthesia was induced with 1.5-2.5 mg/kg propofol and 1-1.5 microg/kg fentanyl given intravenously. Desflurane, 3%, in combination with 60% nitrous oxide in oxygen was administered for maintenance of general anesthesia. In the control group, the inspired desflura...
Use of acupressure as part of a multimodal prophylactic antiemetic regimen Financial support: The... more Use of acupressure as part of a multimodal prophylactic antiemetic regimen Financial support: The active and sham Pressure Right® acupressure devices were provided by Therapeutics: 101 Inc. Dr. White receives support from the White Mountain Institute, a private non-for-profit education and research foundation. .
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