Ketan Shevde

A Survey of 800 Patients' Knowledge, Attitudes, and Concerns Regarding Anesthesia

The present study was undertaken to assess patients knowledge, attitudes, and concerns regarding anesthetic management. A survey of 34 items was developed and administered preoperatively to 800 consecutive patients. Included were 303 men and 497 women with a mean age 52 yr and a mean educational level of 12 yr. Patients were interviewed on their knowledge of the role and training of anesthesiologists and on their preferences regarding anesthetic management. Patients also rated the intensity of their concern on 20 written statements expressing potential anesthetic complications. Results indicated that patients perceptions of the anesthesiologists training and role were accurate. Most patients preferred (a) general to regional anesthesia and (b) not to select their own anesthesiologist. Most significant preoperative concerns regarding the anesthesiologist focused on experience, qualifications, and presence or absence during the anesthesia. Patient concerns also included the possibility of not waking up postoperatively, experiencing pain, and becoming paralyzed. Intensity of concern was inversely related to age and unrelated to educational level or occupation. Variables related to type of concern included patients sex, type of anesthesia, and proposed surgical procedure. Issues of least concern included disclosure of personal matters during anesthesia, experiencing impaired judgment postoperatively, and being asleep or bedridden for a prolonged period of time. It is suggested that anesthesiologists address significant patient concerns during the preoperative visit to enhance their effectiveness in patient care. Efforts to educate the public on the anesthesiologists role in perioperative care should improve patient confidence.

Acupressure Treatment for Prevention of Postoperative Nausea and Vomiting

Postoperative nausea and vomiting are still common problems after general anesthesia, especially in ambulatory surgery.Drug therapy is often complicated with central nervous system symptoms. We studied a nonpharmacological method of therapy-acupressure-at the Pericardium 6 (P.6) (Nei-Guan) meridian point. Two hundred consecutive healthy patients undergoing a variety of short surgical procedures were included in a randomized, double-blind study: 108 patients were in the acupressure group (Group 1) and 92 patients were in the control group (Group 2). Spherical beads of acupressure bands were placed at the P.6 points in the anterior surface of both forearms in Group 1 patients, while in Group 2 they were placed inappropriately on the posterior surface. The acupressure bands were placed before induction of anesthesia and were removed 6 h postoperatively. They were covered with a soft cotton wrapping to conceal them from the blinded observer who evaluated the patients for presence of nausea and vomiting and checked the order sheet for any antiemetics prescribed. In both groups, the age, gender, height, weight, and type and duration of surgical procedures were all comparable without significant statistical difference. In Group 1, only 25 of 108 patients (23%) had nausea and vomiting as compared to Group 2, in which 38 of 92 patients (41%) had nausea and vomiting (P = 0.0058). We concluded that acupressure at the P.6 (Nei-Guan) point is an effective prophylaxis for postsurgical nausea and vomiting and therefore a good alternative to conventional antiemetic treatment. (Anesth Analg 1997;84:821-5)

Headache prevention following accidental dural puncture in obstetric patients

STUDY OBJECTIVEnTo evaluate the efficacy of a prophylactic saline patch and a prophylactic blood patch in prevention of headache following accidental dural puncture in obstetric patients.nnnDESIGNnProspective, randomized, single-blind study on dural puncture headache occurrence and cessation.nnnSETTINGnInpatient obstetric unit at a metropolitan medical center.nnnPATIENTSnSeventy-four inpatients who underwent vaginal delivery or cesarean section following accidental dural puncture during administration of epidural anesthesia for labor and delivery.nnnINTERVENTIONSnGroup 1 (n = 24), the control group, received fluids and analgesics. Group 2 (n = 30) received prophylactic epidural saline (40 to 60 ml) through the epidural catheter following completion of the obstetric procedure. Group 3 (n = 20) received autologous blood (15 ml) via epidural catheter following completion of the obstetric procedure.nnnMEASUREMENTS AND MAIN RESULTSnIn Group 1, 21 of 24 patients (87.5%) developed headaches, with conservative management. In Group 2, 20 of 30 patients (66.7%) developed headaches, and in Group 3, 1 of 20 patients (5%) developed a headache.nnnCONCLUSIONSnThe results of this study suggest that the administration of a prophylactic epidural blood patch is highly effective in the prevention of headaches following dural puncture, with headache frequency reduced from 87.5% to 5%.

Gender is an essential determinant of blood transfusion in patients undergoing coronary artery bypass graft procedure

STUDY OBJECTIVEnTo determine factors that account for gender difference in the need for blood transfusion in coronary artery bypass graft (CABG) patients.nnnDESIGNnRetrospective study of consecutive patients.nnnSETTINGnAnesthesiology department of a teaching hospital.nnnPATIENTSn253 CABG patients (163 males and 90 females).nnnINTERVENTIONSnPacked red blood cells (PRBCs), platelets, and fresh frozen plasma (FFP) were transfused depending on the need of each patient.nnnMEASUREMENTS AND MAIN RESULTSnFor each patient, we recorded the gender, age, weight, height, body surface area (BSA), and duration of surgery. Hematocrit (Hct) levels prior to surgery, end of surgery, and at discharge from the hospital were recorded. PRBC administration and use of FFP and platelets were noted. Differences between the data for female and male patients were evaluated using Students t-test, Chi-square test, and regression analysis. Approximately 60% female and only 20% male patients received PRBCs intraoperatively, whereas 78% females and only 43% males received PRBCs during their entire hospital stay. On average, females received 1.20 units of PRBCs intraoperatively and 2.38 units during the entire hospital stay, while the males received 0.31 units and 1.36 units for similar periods. Gender differences in PRBC transfusion persisted even when females and males were compared within the same subgroups for age, weight, duration of surgery, and preoperative Hct. PRBC units given intraoperatively had a significant correlation with age and preoperative Hct in females, but they had a significant correlation with age, preoperative Hct, and duration of surgery in males. PRBCs given during the entire hospital stay, however, had significant correlation with age, preoperative Hct, and duration of surgery in both females and males. Multiple logistic regression analysis showed that the probability of a patient receiving or not receiving PRBC transfusion is significantly influenced by age, preoperative PRBC mass, duration of surgery, and gender.nnnCONCLUSIONnGender is an independent essential determinant of blood transfusion in CABG patients, and it may interact with age, weight, preoperative Hct, duration of surgery, and other factors in determining the probability of transfusion.

Comparison of intrathecal meperidine and lidocaine in endoscopic urological procedures

The purpose of this study was to determine if a small dose of intrathecal meperidine would achieve adequate spinal anaesthesia while minimizing complications and to compare its effectiveness with lidocaine. The spinal anaesthetic effects of five per cent lidocaine 0.5 mg · kg−1 in 7.5 percent glucose (n = 20) or five per cent meperidine 0.5 mg · kg−1 (n = 22) were evaluated in 42 ASA physical status II or III patients. Intrathecal injection of the anaesthetic agent was given with the patient in the sitting position in which he remained for ten minutes before being placed in the lithotomy position. The onset time for sensory blockade was seven minutes in the lidocaine group and ten minutes in the meperidine group. Final sensory levels were identical in both groups. Mean arterial blood pressure decreased significantly in the lidocaine group but not in the meperidine group. Motor block was absent in ten patients in the meperidine group but was present in all the patients in the lidocaine group. Duration of postoperative analgesia was 968 min in the meperidine group and 681 min in the lidocaine group (NS). Complications such as nausea, vomiting, itching, drowsiness and respiratory depression were similar in the two groups. It is concluded that low-dose meperidine, 0.5 mg · kg−1, is effective as a spinal anaestheic agent and has few complications.RésuméNous avons évalué la mépéridine intrathécale en tant qu’anesthésique, et l’avons comparé à la lidocaine. En position assise, on fit une injection sousarachnoidienne de 0,5 mg-kg−1 de lidocaine cinq pour cent dans du dextrose 7,5 pour cent (n = 20) ou de 0,5 mg · kg−1 de mépéridine cinq pour cent (n = 22) à 42 patients de classe ASA II ou III. Dix minutes plus tard le patient etait place en lithotomie. Le bloc sensitif apparaissait au bout de sept minutes avec la lidocaine et de dix minutes avec la mépéridine et atleignait un niveau final semblable avec les deux agents. Une baisse de la pression artérielle moyenne et un bloc moteur survenaient avec la lidocaine mais pas avec la meperidine. L’analgésie postopératoire durait en moyenne 968 min avec la mépéridine et 681 min avec la lidocaine (NS). La prévalence de nausee, de vomissement, de prurit et de dépression respiratoire était semblable entre les deux groupes. Il semble done qu ’ à dose de 0,5 mg · kg−1, la mépéridine intrathécale soit un anesthésique efficace amenant peu de complications.

Effects of clear liquids on gastric volume and pH in healthy volunteers.

The effects of clear liquids on gastric volume and pH were examined in 30 healthy ASA physical status I volunteers. After overnight fasting, a Salem‐sump nasogastric tube was inserted and gastric contents were removed for measurement of volume and pH. Gastric contents were then reinserted through the nasogastric tube into the stomach. The volunteers were randomly divided into three groups: group 1 (n = 10) received 240 mL water, group 2 (n = 10) received 240 mL coffee, and group 3 (n = 10) received 240 mL pulp‐free orange juice. All liquids were administered orally. Gastric contents were then again aspirated, measured for volume and pH, and reinserted through the nasogastric tube every half hour until gastric volume was<25 mL. All volunteers had gastric volumes<25 mL with a slight decrease in pH within 2 h of orally taking one of the three 240-mL liquids. These data suggest that if patients have ingested a moderate amount of clear liquids it is safe to conduct general anesthesia after a 2-h fast in healthy surgical patients.

Preoperative blood volume deficit influences blood transfusion requirements in females and males undergoing coronary bypass graft surgery

STUDY OBJECTIVEnTo evaluate whether preoperative blood volume and postoperative blood loss influence blood transfusion in females and males undergoing coronary artery bypass graft (CABG) surgery.nnnDESIGNnProspective study.nnnSETTINGnAnesthesiology department of a teaching hospital.nnnPATIENTSn57 CABG patients (21 females and 36 males).nnnMEASUREMENTSnBlood volume was determined using the radioactivity dilution method. Preoperatively, each patient received intravenous (IV) injection of 1 mL Albumin I(131) tracer having 25 microcuries of radioactivity. Five-milliliter blood samples were collected at different intervals. From these samples, hematocrit (Hct) value, preoperative total blood volume, red blood cell (RBC) volume, and plasma volume were determined. Postoperatively, some consenting patients received another 1 mL dose of the tracer, and the postoperative blood volumes were determined. If a patient received a blood transfusion, the units of packed red blood cells (PRBCs), platelets, or fresh frozen plasma (FFP) transfused were recorded. For each patient we recorded the gender, age, weight, height, body surface area (BSA), preoperative Hct, duration of surgery, and discharge Hct.nnnRESULTSnPreoperatively, the mean total blood volume, RBC volume, and plasma volume, respectively, were 2095 mL/m(2), 631 mL/m(2), and 1,465 mL/m(2) in females; and 2,580 mL/m(2), 878 mL/m(2), and 1,702 mL/m(2) in males. The preoperative blood volumes were significantly lower (p < 0.01) in females than in males. There was no significant difference between males and females in the extent of blood loss during CABG. Intraoperatively, females received PRBC transfusion of 1.38 units, significantly more (p < 0.01) than the 0.39 units received by males. During the entire hospital stay, females received 4.33 units of PRBC, significantly more than (p < 0.02) the 1.33 units received by males. Significantly more (p < 0.01) females (12 of 21) received intraoperative PRBC transfusion than did males (6 of 36). Multiple logistic regression analysis of the data showed that PRBC transfusion was significantly correlated with the preoperative total blood volume and RBC volume.nnnCONCLUSIONnThe greater need for blood transfusion in females than in males during CABG is primarily attributable to significantly lower preoperative total blood volume and RBC volume in females.

Adenosine and myocardial protection

A DENOSINE (ADO, MW = 267.24) is an endogenous nucleoside (Fig I), which is the end-product of highenergy adenosine triphosphatc (ATP) catabolism during reduced oxygen (02) supply/demand states resulting from hypoxia and ischemia.’ In regard to the cardiovascular system, ADO may be considered a self-protective hormone or autocoid, because it is secreted by myocardial cells during ischemiaihypoxia while having many beneficial effects against arrhythmias, myocardial ischemia. and reperfusion ischemia.‘-a Leung et al” have published the first preliminary evidence that 5aminoimidazole-4-carboxamide riboside (AICAR) infusion reduces the frequency of perioperative myocardial infarctions (PMI) during coronary artery bypass graft (CABG) by increasing endogenous ADO in ischemic myocardium. The following is a critical review of published Englishlanguage articles regarding residual myocardial injury and potential metabolic therapy with either ADO or AICAR during CABG surgery.

Catheter-induced innominate vein perforation: anatomical considerations.

Complication souvent mortelle. Un cas devolution favorable apres mise en place dun catheter dans lartere pulmonaire

Decreasing the risk of pulmonary artery rupture with a pressure relief balloon

A pressure relief balloon has been recommended as one way to decrease catheter-related pulmonary artery rupture (PAR). There are approximately 1 to 2 PARs per 1,000 pulmonary artery catheter (PAC) insertions, resulting in significant morbidity and mortality. A new pressure relief balloon (PRB) introduced by Biosensors International (Singapore) was studied for its efficacy in increasing safety during PAC flotation balloon (FB) inflations. Ten human placentae were used for the experiment. The Biosensors PACs and the commonly used Baxter-Edwards (Irvine, CA) catheters were placed in placental veins and their FBs were gradually inflated with a maximum of 1.5 mL of air. Data revealed that PRBs consistently inflated when resistance was met by FBs and inflation pressure reached 1,000 mmHg. When PRBs were removed, the FBs inflated asymmetrically and distended beyond the catheter lumen or protruded through the vessel wall, causing bleeding upon deflation. Without the PRB, pressures reached up to 1,700 mmHg. In addition, the PRB gave visual evidence of resistance to the FB. In conclusion, the PRB is a safety device that limits overinflation of the distal PAC balloon, thus preventing vessel rupture. The device deserves serious consideration and outcome analysis.