A double-blind comparison of ropivacaïne 0.5%, 0.75%, 1.0% and bupivacaine 0.5%, injected epidurally,in patients undergoing abdominal hysterectomy

Purpose

Ropivacaïne is a new long-acting, injectable local anaesthetic currently undergoing clinical investigation world wide. It is structurally very similar to bupivacaine, but with less potential for central nervous system or cardiac toxicity. The purpose of this double-blind study was: to investigate the dose-response relationship of increasing doses of ropivacaïne on the quality of anaesthesia and the duration of both motor and sensory blockade, and to compare these results with an established local anaesthetic, bupivacaine.

Methods

One hundred and twenty five patients were randomly assigned to one of four treatment groups and 116 completed the study. Epidural anaesthesia was established using 25 ml test solution, injected over three minutes following a satisfactory test dose. Sensory onset, spread and duration, using the pin prick method, and motor scores using a modified Bromage scoring system were compared.

Results

A dose/response relationship was observed with increasing doses of ropivacaïne for all variables tested except analgesia and muscle relaxation (P < 0.01). There were differences in: (i) motor onset (Levels 1 and 2), when ropivacaïne 1.0% was compared with ropivacaïne 0.75% and 0.5% (P < 0.05); (ii) in sensory duration at all levels except T₆ when ropivacaïne was compared with ropivacaïne 0.5% (P < 0.05); (iii) differences in sensory duration at T₁₂ and S₁ when ropivacaïne 1.0% was compared with bupivacaine 0.5% (P < 0.05); (iv) differences in motor duration at all levels when ropivacaïne 1.0% was compared with ropivacaïne 0.5% (P < 0.05). No serious adverse events were reported in this study.

Conclusion

Increasing doses of ropivacaïne were associated with an increased clinical effect. The most consistent differences occurred when ropivacaïne 1.0% was compared with 0.5% and the least consistent between ropivacaïne 0.5%, 0.75% and bupivacaine 0.5%. The main difference between ropivacaïne 1.0% and bupivacaine was in sensory duration. No serious adverse events were reported.     

Topical methylprednisolone vs lidocaïne for the prevention of postoperative sore throat

OBJECTIVE: We assessed the efficacy of topical methylprednisolone or lidocaine for prevention of postoperative sore throat. STUDY DESIGN: Randomised, prospective in single blind study. PATIENTS AND METHODS: Sixty patients ASA 1 or 2 undergoing tracheal intubation for dental surgery received before intubation either topical lidocaine 5% (15 puffs) or aerosolized methylprednisolone (80 mg). Postoperative pain was assessed by the patients using a VAS and a specific scoring system for sore throat, cough and hoarseness. Evaluations were performed immediately after emergence from anaesthesia, 1 h later, at time of the first postoperative drink, at time of the first postoperative meal and 24 h after surgery. RESULTS: Patients receiving methylprednisolone showed slightly better scores for sore throat and cough 1 h after surgery. CONCLUSION: Topical methylprednisolone may therefore be a useful adjuvant in the prevention of sore throat after intubation.     

A comparison of the new ROTEM®sigma with its predecessor,the ROTEMdelta

Thromboelastometry point-of-care coagulation testing facilitates optimised management of bleeding. Previous thromboelastometry systems required the blood sample and liquid reagents to be pipetted in several manual steps by trained personnel. The ROTEMsigma coagulation analyser is a fully automated point-of-care device. We aimed to assess the reference ranges of the new device and to compare the results with those of the predecessor device, the ROTEMdelta. We took blood from healthy volunteers and from hyper- or hypocoagulable patients; blood samples from healthy volunteers served to determine reference ranges for the most important parameters for the ROTEMsigma: CT_EXTEM 48–61 s; A5_EXTEM 30–51 mm; MCF_EXTEM 54–70 mm; CT_INTEM 138–174 s; MCF_INTEM 51–67 mm and MCF_FIBTEM 5–24 mm. We then used blood samples from patients to compare the results obtained between the old and the new device. We found a strong correlation between the same tests performed on two ROTEMsigma devices and between the ROTEMsigma and the ROTEMdelta with respect to the determination of thromboelastometry parameters of hyper- and hypocoagulable patients (all p < 0.001 and R > 0.8). Performance evaluation for the ROTEMsigma device showed very high precision (R > 0.99, p < 0.001). Our reference ranges can serve as an important aid for other hospitals using this new device.     

A comparison of ondansetron and prochlorperazine for the prevention of nàusea and vomiting after tympanoplasty

Purpose

To evaluate the effects on PONV and headache after tympanoplasty of prochlorperazine 0.2 mg·kg^?1 im, ondansetron 0.06 mg·kg^?1 iv or placebo (isotonic saline) 0.02 ml·kg^?1 iv given immediately after induction of anaesthesia prior to tracheal intubation.

Methods

The study was randomised, double blind and prospective. One hundred and forty-eight patients, aged 9–61 yr, received a standardised balanced inhalational anaesthetic with controlled ventilation and induced hypotension. Postoperatively, the frequencies of retching and vomiting in the PACU and of nausea, retching, vomiting, headache, analgesic and antiemetic requirements in the surgical ward for 24 hr were recorded.

Results

The four test groups (n = 37 each) were comparable. The incidences of vomiting in the PACU were similar. During the first 24 hr after surgery the antiemetics produced no reductions in the incidence of nausea alone or of vomiting alone. However, the combination of nausea and vomiting was reduced from 53% (placebo) to 16% (P < 0.0005), 19% (P < 0.0005) and 30% (P < 0.05) by im. prochlorperazine, iv ondansetron and iv prochlorperazine, respectively. The frequency of those experiencing no PONV was increased from 27% (placebo) by prochlorperazine im to 57% (P < 0.01), by ondansetron iv to 62% (P < 0.005) and by prochlorperazine iv to 43% (P = NS). The. onset of PONV was delayed in those given prochlorperazine im, and vomiting was less severe in those given ondansetron iv. Headache occurred with similar frequency in each group.

Conclusion

Prophylactic prochlorperazine 0.2 mg·kg^?1 im and ondansetron 0.06 mg·kg^?1 iv are similarly efficacious in reducing nausea with vomiting after tympanoplasty, while prochlorperazine 0.1 mg·kg^?1 iv is less efficacious. Neither drug given as described appeared to reduce the frequency of postoperative nausea alone or vomiting alone.     

Predicting Acute Appendicitis? A comparison of the Alvarado Score,the Appendicitis Inflammatory Response Score and Clinical Assessment

Background

Patients presenting with suspected appendicitis pose a diagnostic challenge. The appendicitis inflammatory response (AIR) score has outperformed the Alvarado score in two retrospective studies. The aim of this study was to evaluate the AIR Score and compare its performance in predicting risk of appendicitis to both the Alvarado score and the clinical impression of a senior surgeon.

Methods

All parameters included in the AIR and Alvarado scores as well as the initial clinical impression of a senior surgeon were prospectively recorded on patients referred to the surgical on call team with acute right iliac fossa pain over a 6-month period. Predictions were correlated with the final diagnosis of appendicitis.

Results

Appendicitis was the final diagnosis in 67 of 182 patients (37 %). The three methods of assessment stratified similar proportions (~40 %) of patients to a low probability of appendicitis (p = 0.233) with a false negative rate of <8 % that did not differ between the AIR score, Alvarado score or clinical assessment. The AIR score assigned a smaller proportion of patients to the high probability zone than the Alvarado score (14 vs. 45 %) but it did so with a substantially higher specificity (97 %) and positive predictive value (88 %) than the Alvarado score (76 and 65 %, respectively).

Conclusions

The AIR score is accurate at excluding appendicitis in those deemed low risk and more accurate at predicting appendicitis than the Alvarado score in those deemed high risk. Its use as the basis for selective CT imaging in those deemed medium risk should be considered.

     

A comparison of the management of blunt splenic injury in children and young people—A New South Wales,population-based,retrospective study

The importance and safety of non-operative management (NOM) of Blunt Splenic Injury (BSI) has been established in children and adults over recent decades. However, studies have shown higher operation rates in adults. There is international evidence that when children are managed in adult centres, operation rates are higher while adolescents in paediatric centres, are operated on in line with paediatric guidelines. This difference between children and young adults, and the factors responsible, have not been examined in New South Wales (NSW).ObjectiveTo use NSW hospital and mortality data to compare the characteristics of BSI in patients aged 0–16 to those aged 17–25, and determine factors related to operative management (OM) and splenic salvage in each group.MethodsPatients age 0–25 between July 2000 and December 2011, with a diagnosis of BSI, were identified in the NSW Admitted Patient Data Collection, and linked to deaths data from Registry of Births Deaths and Marriages and Bureau of Statistics. Operation rate was compared between the two groups. Univariable analysis was used to determine factors associated with OM. Multivariable logistic regression with stepwise elimination was then performed to determine likelihood of OM according to age group, adjusting for potential confounders.Results1986 cases were identified, with 422 (21.2%) managed operatively – 101/907 children (11.1%) and321/1079 (29.7%)young adults(p < 0.001). Of these, 59 (58%) children underwent splenectomy compared with 233 (73%) young adults (p < 0.001). OM increased significantly after the age of 12 (p = 0.03), and the percentage almost tripled in the teenage years, coinciding with a higher proportion admitted to adult centres. OM doubled again in young adults(p < 0.001), all of whom were managed away from paediatric centres. On multivariable analysis, factors significantly associated with operation included age over 16 (OR 2.82, 95%CI 2.10-3.81), splenic injury severity, associated thoracic, liver, pancreatic and hollow viscus injury, and blood transfusion.ConclusionWhile Paediatric Surgeons have wholeheartedly adopted non-operative management, away from paediatric centres, it is possible children and young people in NSW are undergoing operation unnecessarily. Further evaluation of the surgeon attitudes and institutional factors involved in the management of injured children and young people within the broad NSW trauma system is required.     

When is the helicopter faster? A comparison of helicopter and ground ambulance transport times

BACKGROUND: A retrospective analysis of 7,854 ground ambulance and 1,075 helicopter transports was conducted. METHODS: The 911-hospital arrival intervals for three transport methods were compared: ground, helicopter dispatched simultaneously with ground unit, and helicopter dispatched nonsimultaneously after ground unit response. RESULTS: Compared with ground transports, simultaneously dispatched helicopter transports had significantly shorter 911-hospital arrival intervals at all distances greater than 10 miles from the hospital. Nonsimultaneously dispatched helicopter transport was significantly faster than ground at distances greater than 45 miles, and simultaneous helicopter dispatch was faster than nonsimultaneous at virtually all distances. Ground transport was significantly faster than either air transport modality at distances less than 10 miles from the hospital. CONCLUSION: Ground ambulance transport provided the shortest 911-hospital arrival interval at distances less than 10 miles from the hospital. At distances greater than 10 miles, simultaneously dispatched air transport was faster. Nonsimultaneous dispatched helicopter transport was faster than ground if greater than 45 miles from the hospital.     

Can the addition of clonidine improve the analgesic efficacy of low dose intrathecal morphine? A randomised double-blind trial

OBJECTIVE: To evaluate the influence of intrathecal clonidine on spinal morphine analgesia and adverse effects after major orthopaedic surgery. METHODS: The study was approved by the local Ethics Committee.After written informed consent, 45 ASA I-III patients scheduled for hip or knee replacement were included. Patients were randomly allocated to receive either placebo, 0.1 mg morphine or 0.1 mg morphine+50 microg clonidine in addition to 15 mg bupivacaine intrathecally. The primary outcome parameter was the time to first opioid request. Statistical differences were calculated with U-test or Fisher's exact test. RESULTS: Clonidine did not result in a significant improvement of postoperative analgesia. The mean time until first opioid request was for placebo 10.3+/-7.9 h, for 0.1 mg morphine 23.0+/-3.9 h and for 0.1 mg morphine+ 50 microg clonidine 21+/-6.9 h, respectively. Clonidine significantly increased the rate of adverse effects. CONCLUSION: Our trial did not confirm an improved analgesia with the combination of intrathecal morphine and clonidine. Due to increased adverse effects the combination of intrathecal clonidine and morphine does not seem to be a reasonable alternative in the management of postoperative pain after orthopaedic surgery.     

Addition of opioids alters the density and spread of intrathecal local anesthetics? Anin vitro study

PURPOSE: To determine whether the addition of opioids alters the density and spread of intrathecal local anesthetics in vitro. METHODS: In Part I, the densities of hyperbaric bupivacaine 0.75% (HB), hyperbaric lidocaine 5% (HL) and isobaric bupivacaine 0.5% (IB) with and without morphine (M), and fentanyl (F) were measured at 22 degrees C. In Part II a model was constructed utilizing a column containing a solution similar in composition to cerebrospinal fluid (CSF) at 37 degrees C. The various local anesthetic-opioid solutions, coloured with crystalline methylene blue dye, were injected at 22 degrees C into the column at a controlled rate through a spinal needle. The direction and extent of spread of the injectates were compared. RESULTS: The relative densities of the five solutions were: HB = HL > IB > M > F. The addition of fentanyl to IB reduced the density of the final solution (P < 0.05). In the model, IB alone and IB with morphine showed mainly downward spread, with the addition of fentanyl to IB resulting in upward movement (P = 0.004). The hyperbaric local anesthetics moved downward with or without opioids. CONCLUSION: The addition of fentanyl reduces the density of IB in vitro and alters its movement in simulated CSF. This may prove to be important in predicting the level of spinal block in clinical practice.     

Does the identity of the bacteria matter in post-Kasai cholangitis? A comparison between simple and intractable cholangitis

Purpose

This study compared the bacteriology and clinical outcomes between simple (SC) and intractable cholangitis (IC) after Kasai operation.

Do smaller adults wait longer for liver transplantation? A comparison of the UK and the USA data

Young AL, Peters CJ, Pocock PV, Millson CE, Prasad KR. Do smaller adults wait longer for liver transplantation? A comparison of the UK and the USA data.
Clin Transplant 2009 DOI: 10.1111/j.1399‐0012.2009.01037.x
© 2009 John Wiley & Sons A/S. Abstract: Background: The number of patients on the UK and the USA liver transplant list is increasing. As size match is an important factor in the UK organ allocation, we studied the effect of recipient size on liver transplantation in the UK and the USA. Methods: The UK Transplant and United Network for Organ Sharing databases were used to assess difference in access to transplantation between smaller adult patients and their larger counterparts over three time periods. Subsequently, proportions of split, NHBD and living‐donor transplants were analyzed. Results: There were 1576 UK and 29 150 USA patients in our analysis. The UK small patients have been significantly disadvantaged in access to transplantation particularly in early years and in adult only transplant units. This contrasts to the USA where smaller patients have never been disadvantaged and transplantation rates are steadily increasing. Split‐liver transplants are being carried out in increasing numbers in the UK but not the USA. Conclusions: Small adults are still less likely to be transplanted at six months in adult only units in the UK. The lack of size matched organs for smaller adults and the overall decrease in rates of transplantation in the UK may be remedied by careful consideration of allocation policy and increased use of innovative techniques.     

Can TOF MRA replace duplex and Doppler sonography in preoperative assessment of the carotid arteries? A prospective comparison and review of the literature

AIM: To examine the quality and usefulness of time-of-flight MR-angiography and duplex-doppler sonography, respectively, in assessment of the extracranial arteries before cervical spine operations. METHODS: Patients scheduled for operations of the cervical spine had an MRI plus TOF as well as a duplex and Doppler scan. At the time of the examination the radiologist and the neurologist in charge were blinded for the study. Endpoints were not only the accuracy of the procedures but more so which method improved the preoperative process most. RESULTS: Twenty patients were examined so far. Only in one case did the result differ when a complete occlusion diagnosed sonographically was judged as a severe stenosis on MRA. One patient did not tolerate the MRA for the extra 5 minutes necessary, therefore a contrast-enhanced MRA was performed. MRA eased the preoperative process as imaging of the pathology and the carotids were realised in one step. The costs were slightly higher for MRA than for duplex-doppler sonography. CONCLUSION: TOF-MRA can replace the duplex-doppler examination in the preoperative assessment of the carotids and has the potential to streamline the preoperative time schedule. Similar to duplex and doppler, in order to be accurate enough the method requires a high degree of expertise from the radiologist.     

Comparison of 50 μg and 25 μg doses of intrathecal morphine on postoperative analgesic requirements in patients undergoing transurethral resection of the prostate with intrathecal anesthesia

Study ObjectiveTo compare the efficacy of 50 μg and 25 μg doses of intrathecal morphine on postoperative pain in patients undergoing transurethral resection of the prostate (TURP) with low-dose bupivacaine.DesignRandomized, double-blinded study.SettingKonya Hospital.Patients70 ASA physical status I, II, and III patients.InterventionsPatients were randomized to two groups: Group A patients received 5 mg of 0.5% hyperbaric bupivacaine (one mL) and 50 μg of morphine (0.5 mL). Group B patients received 5 mg of 0.5% hyperbaric bupivacaine (one mL) and 25 μg of morphine (0.5 mL).MeasurementsPostoperative pain scores, patient and surgeon satisfaction, and side effects such as emesis, pruritus, and respiratory depression, were recorded.Main ResultsPostoperative pain characteristics were similar between the two groups. Frequency of emesis was similar between the groups, while pruritus was significantly higher in Group A. No antipruritic medication was required in any patient. Patient and surgeon satisfaction was evaluated as good or excellent in both groups.ConclusionsIntrathecal morphine at a dose of 25 μg provides similar postoperative analgesia and less pruritus than the 50 μg dose in patients undergoing TURP.     

Comparison of the effects of human β-defensin 3, vancomycin, and clindamycin on Staphylococcus aureus biofilm formation

Despite improvements in surgical techniques and implant design in orthopedic surgery, implantation-associated infections are still a challenging problem for surgeons. In 2006, trace quantities of human β-defensin 3 (hBD-3) were found in human bone tissue and bone cells. Human β-defensin 3 is a 45-amino-acid peptide that is considered the most promising class of defensin antimicrobial peptides and may help in the prevention and treatment of implantation-associated infections. Studies of the effectiveness of hBD-3 against Staphylococcus aureus showed that hBD-3 was more potent at low concentrations than other antibiotics. The effect of hBD-3 on S aureus biofilms has not been reported. We studied the effect of hBD-3, vancomycin, and clindamycin on S aureus biofilms and on the survival of the bacteria in the biofilms.Staphylococcus aureus biofilms were examined with confocal scanning laser microscopy. Staining with LIVE/DEAD BacLight viability stain (Molecular Probes Europe BV, Leiden, The Netherlands) differentiated between live and dead bacteria within the biofilms, and extracellular polymeric substances (slime) from the biofilms was evaluated after staining with calcofluor white (Sigma Chemical Company, Rocky Hill, New Jersey). Human β-defensin 3 and clindamycin reduced the S aureus biofilm area. Human β-defensin 3 was significantly more effective against bacteria from the S aureus biofilms than was clindamycin. Vancomycin did not reduce the S aureus biofilm area.     

Heterotopic ossification after hemiarthroplasty of the hip – A comparison of three common approaches

Objective

Heterotopic ossification (HO) about the hip after total hip arthroplasty and internal fixation of the hip, pelvis, and acetabulum has been linked to surgical approach. However, no study has investigated surgical approach and HO in patients undergoing hemiarthroplasty. We therefore aimed to explore the influence of operative approach in patients undergoing hemiarthroplasty.

Methods

Through a retrospective case series at an Urban level I trauma center, we found 80 patients over the age of 60 undergoing hemiarthroplasty for femoral neck fractures from 2000 to 2009. Patient charts, operative notes, and radiographs were reviewed for demographics, operative approach (anterior: A, anterior-lateral: AL, posterior: P), and any development of HO. Fisher''s exact test compared rates of HO among the three approaches. Student''s t-tests compared Brooker Classification levels of HO among the approaches.

Results

82 hemiarthroplasties (26 A, 32 AL, 24 P) were included for analysis. 22 patients (27%) had HO. There was no significant difference in the development of HO based upon surgical approach: A: 19% (n = 5); AL: 34% (n = 11); P: 25% (n = 6). There was a significant difference in the grade of HO based on Brooker Classification (BC) with the posterior approach resulting in significantly lower grade of HO: A (BC: 2.60); AL (BC: 2.64); P (BC: 1.50) (p = 0.012).

Conclusions

Our data is the first to evaluate surgical approach and HO in patients with hemiarthroplasty. Patients have a significant risk of developing higher grade HO based on surgical approach (A or AL). Orthopedists should be mindful of these risks when considering A or AL approaches.     

A comparison of the Nexfin® and transcardiopulmonary thermodilution to estimate cardiac output during coronary artery surgery

The newly introduced Nexfin^® device allows analysis of the blood pressure trace produced by a non‐invasive finger cuff. We compared the cardiac output derived from the Nexfin and PiCCO, using transcardiopulmonary thermodilution, during cardiac surgery. Forty patients with preserved left ventricular function undergoing elective coronary artery bypass graft surgery were studied after induction of general anaesthesia and until discharge to the intensive care unit. There was a significant correlation between Nexfin and PiCCO before (r² = 0.81, p < 0.001) and after (r² = 0.56, p < 0.001) cardiopulmonary bypass. Bland–Altman analysis demonstrated the mean bias of Nexfin to be ?0.1 (95% limits of agreement ?0.6 to +0.5, percentage error 23%) and ?0.1 (?0.8 to +0.6, 26%) l.min^?1.m^?2, before and after cardiopulmonary bypass, respectively. After a passive leg‐raise was performed, there was also good correlation between the two methods, both before (r² = 0.72, p < 0.001) and after (r² = 0.76, p < 0.001) cardiopulmonary bypass. We conclude that the Nexfin is a reliable method of measuring cardiac output during and after cardiac surgery.