Pekka Rautoma

Comparison of 27-gauge (0.41-mm) Whitacre and Quincke spinal needles with respect to post-dural puncture headache and non-dural puncture headache.

Background:  The incidence of headache after spinal anaesthesia has varied greatly between studies. We compared the incidence of postoperative headache in general and postdural puncture headache (PDPH) when using 27‐gauge (G) (outer diameter 0.41 mm) Quincke and Whitacre spinal needles in ambulatory surgery performed under spinal anaesthesia.

Comparison of airway management with the intubating laryngeal mask, laryngeal tube and CobraPLA® by paramedical students in anaesthetized patients

Background:  Because of the importance of airway management in emergency care, alternative methods with shorter learning curves for inexperienced personnel have been looked for as a substitute for endotracheal intubation (ETI).

Mivacurium When Precedent by Pancuronium Becomes a Long-acting Muscle Relaxant

Background To ensure rapid recovery of neuromuscular block, it might be useful to administer a short‐acting relaxant after a long‐acting one. Therefore, the interaction between pancuronium and mivacurium was investigated when mivacurium was administered during the recovery from pancuronium block. Methods After written informed consent, 41 adult patients were studied during propofol/alfentanil/nitrous oxide/oxygen anesthesia. Neuromuscular function was monitored using an electromyographic (EMG) method. After a stable EMG calibration response, cumulative doses of pancuronium were given to establish a 95% neuromuscular block. In the control group, an ED95 dose of 100 micro gram/kg mivacurium was administered instead of pancuronium. When the EMG response after pancuronium or mivacurium had recovered to 25% of the baseline, a single randomized intravenous bolus dose of 10 or 70 micro gram/kg mivacurium was given. Thereafter, spontaneous recovery of the neuromuscular function was recorded. Results The time from pancuronium until T1 25% EMG recovery was 38 +/‐12 min (mean+/‐SD). The respective times after 10 or 70 micro gram/kg mivacurium were 28+/‐8 and 54+/‐7 min in the pancuronium group or 3+/‐1 (n = 3) and 10+/‐4 min in the mivacurium group (P = 0.0001). Times to 95% EMG recovery after 10 or 70 micro gram/kg mivacurium were 77+/‐14 and 97+/‐16 min in the pancuronium group and 11+/‐3 and 20+/‐7 min in the mivacurium group, respectively (P < 0.0001). Recovery indexes after 10 or 70 micro gram/kg mivacurium were 26+/‐4 and 22+/‐ 6 min in the pancuronium group or 7+/‐3 (n = 3) and 5+/‐ 2 min in the mivacurium group, respectively (P < 0.0001). Times from the administration of 10 or 70 micro gram/kg mivacurium until train‐of‐four ratio 0.7 were 94+/‐16 and 111+/‐14 min in the pancuronium group and 12+/‐4 and 22+/‐8 min in the mivacurium group, respectively (P < 0.0001). Conclusions After pancuronium, mivacurium is not a short‐acting neuromuscular blocking agent.

Rocuronium in infants, children and adults during balanced anaesthesia

We studied 20 infants, 20 children and 20 adults during balanced anaesthesia to compare the neuromuscular blocking effects of rocuronium in these age groups. Neuromuscular function was recorded by adductor pollicis emg and a cumulative log‐probit dose‐response curve of rocuronium was established. Thereafter, full spontaneous recovery of the neuromuscular function was recorded. Onset time of the first dose of rocuronium was shorter in children than in infants or adults. The potency of rocuronium was greatest in infants and least in children; the ED50 doses (mean ± SD) being 149 ± 36 μg˙kg−1 in infants, 205 ± 52 μg˙kg−1 in children and 169 ± 47 μg˙kg−1 in adults (P<0.05 between infants and children) and the ED95 doses being 251 ± 73 μg˙kg−1, 409 ± 71 μg˙kg−1 and 350 ± 77 μg˙kg−1, respectively (P<0.05 between all groups). The emg recovery following an average 94.5 ± 4.8% neuromuscular blockade established by rocuronium was roughly similar in all study groups. Thus, one ED95 dose of rocuronium, unlike vecuronium, acts as an intermediate‐acting agent in all age groups.

Diclofenac premedication but not intra-articular ropivacaine alleviates pain following day-case knee arthroscopy.

Purpose: To compare the postoperative analgesic effects of 50 mg diclofenacpo before surgery and intra-articular ropivacaine injected after diagnostic day-case knee arthroscopy performed under spinal anesthesia.Methods: In a randomized, double-blind investigation, 200 ASA physical status 1–2 outpatients, age 18–60 yr, received either 50 mg diclofenacpo or placebo one hour before operation (100 patients per group), and intra-articular injections of either 20 ml of ropivacaine 0.5% or 20 ml of saline 0.9% (50 patients in each premedication groups). Patients received 50 mg diclofenacpo prn and, if needed, 0.1 mg·kg−1 oxycodoneim for postoperative pain relief. Patients were discharged home with a supply of 50 mg diclofenac tablets and were given a sheet of paper with knee pain VAS scales and a questionnaire of analgesics taken. Patients rated their VAs scores eight hours after surgery and in the morning and at the end of the first and the second postoperative days, respectively.Results: The only statistically significant difference was found when the diclofenac groups were combined and compared with the combined placebo premedication groups. The VAS scores of knee pain at eight hours after the operation were 19±22 in the two diclofenac premedication groups and 32±28 in the two placebo groups (P=0.001).Conclusions: Diclofenac premedicationpo reduced the VAS scores at eight hours postoperatively while intra-articular ropivacaine did not.RésuméObjectif: Comparer les effets analgésiques postopératoires de 50 mg de diclofénacpo, administrés avant l’opération, à la ropivacaïne intra-articulaire, donnée parès l’arthroscopie diagnostique sous rachianesthésie.Méthode: Lors d’une étude randomisée et en double aveugle, 200 patients d’état physique ASA I–II, âgés de 18–60 ans, ont reçu 50 mg de diclofénacpo ou un placebo une heure avant l’opération (100 patients par groupe), et une injection intra-articulaire de 20 ml de ropivacaïne 0,5 % ou 20 ml de solution salée 0,9% (50 patients dans chaque groupe de prémédication). Les patients ont reçu 50 mg de diclofénacpo prn/it et, si nécessaire, 0,1 mg·kg−1 d’oxycodoneim pour soulager la douleur postopératorie. À leur départ, ils ont reçu des comprimés de 50 mg de diclofénac, un questionnaire concernant la prise d’analgésiques et une feuille de papier où inscrire le niveau de douleur au genou selon l’EVA. Les patients ont estimé leurs scores à l’EVA huit heures parès l’opération et au début et à la fin du premier et du deuxième jours postopératoires, respectivement.Résultats: La seule différence statistique significative a été trouvée en combinant les groupes de diclofénac et en les comparant aux groupes combinés de prémédication placebo. Les scores postopératoires de l’EVA ont été de 19±22 dans les deux groupes qui ont reçu une prémédication de diclofénac et de 32±28 dans les groupes qui ont reçu le placebo (P=0,001).Conclusion: La prémédication au diclofénacpo a réduit les scores postopératoires de l’EVA à huit heures, mais non pas la ropivacaïne intra-articulaire.

Smoking increases the requirement for rocuronium

PurposeTo compare the potency of rocuronium in non-smokers and smokers during general anaesthesia.MethodsIn a randomized, open clinical study, 40 patients, 17–62 yr of age, were anaesthetized with propofol, alfentanil and nitrous oxide in oxygen. After obtaining individual dose-response curves for rocuronium, bolus doses of rocuronium were given to maintain neuromuscular block at 90–99% for 60 min. Evoked adductor pollicis electromyography (EMG) was used to monitor neuromuscular block.ResultsThe ED95 values (± SEM) for rocuronium were 460.5 ± 28.9 and 471.5 ± 22.1 μg·kg−1 for nonsmokers and smokers, respectively (P:NS). However, doses of rocuronium to maintain 90–99% neuromuscular block (± SEM) were 620.1 ± 46.7 and 747.4 ± 56.0 μg·kg−1·hr−1 for non-smokers and smokers, respectively (P = 0.0504).ConclusionThe results may indicate increased metabolism of rocuronium in smokers rather than increased requirement of rocuronium at the receptor site.RésuméObjectifComparer l’action du rocuronium chez des non fumeurs et des fumeurs pendant l’anesthésie générale.MéthodeDans une étude clinique randomisée et ouverte, 40 patients, de 17 à 62 ans, ont reçu une anesthésie avec du propofol, de l’alfentanil et un mélange de protoxyde d’azote et d’oxygène. Après avoir obtenu les courbes individuelles de dose-réponse au rocuronium, des bolus de rocuronium ont été administrés pour maintenir le bloc neuromusculaire à 90–99% pendant 60 min. L’électromyographie (EMG) de l’adducteur du pouce a été utilisée pour surveiller le bloc neuromusculaire.RésultatsLes valeurs de la ED95 (± écart-type) ont été, pour le rocuronium, de 460,5 ± 28,9 et de 471,5 ± 22,1 μg·kg−1 pour les non fumeurs et les fumeurs, respectivement (P: NS). Cependant, les doses de rocuronium administrées pour maintenir un bloc neuromusculaire à 90–99% (± écart-type) ont été de 620,1 ± 46,7 et de 747,4 ± 56,0 μg·kg−1 ·hr−1 pour les non fumeurs et les fumeurs, respectivement (P = 0,0504).ConclusionLes résultats peuvent indiquer un accroissement du métabolisme du rocuronium chez les fumeurs plutôt qu’un accroissement des besoins en rocuronium au site récepteur.

Synergism between mivacurium and pancuronium in adults

Mivacurium could be a useful agent as a final dose of a muscle relaxant following pancuronium if only additivily exists between these agents. We examined the interaction between mivacurium and pancuronium in 70 patients (ASA I‐II) during propofol‐alfentanil‐N2O‐C2 anaesthesia. Neuromuscular function was monitored by adductor pollicis EMG.

Interaction between mivacurium and succinylcholine.

We investigated the interaction between mivacurium and succinylcholine when mivacurium was administered during the early recovery from succinylcholine block.We studied 40 adult patients during propofolalfentanil-N2 O-O2 anesthesia. Neuromuscular function was monitored using an electromyographic method (Relaxograph Registered Trademark; Datex, Helsinki, Finland). Patients randomly received either 1.0 mg/kg of succinylcholine followed by 0.15 mg/kg of mivacurium when the first twitch (T1) during succinylcholine block recovered to 5%, or 0.15 mg/kg of mivacurium without succinylcholine. Serum cholinesterase activity was lower than normal range in two patients and higher than normal range in four patients, but the dibucaine number value was normal in every patient. The mean onset time (3.8 +/- 0.9 min) (mean +/- SD) or maximal neuromuscular block (96.6% +/- 7.2%) of mivacurium did not differ between the groups. The T1 recovery times of mivacurium were slightly shorter (P < 0.05) after succinylcholine administration than without it. During recovery of mivacurium block, the fade was significantly greater, i.e., the train-of-four (TOF) ratio was lower, after succinylcholine administration than without it. Recovery index (T1 25%-75%, mean 4.7 +/- 1.3 min) and the time from the administration of mivacurium to the recovery of TOF ratio 0.7 (mean 20.4 +/- 5.1 min) were not different between the groups. In conclusion, in healthy patients succinylcholine has negligible effects on a subsequent mivacurium-induced neuromuscular block. (Anesth Analg 1995;80:534-7)

Potency and maintenance requirement of atracurium and vecuronium given alone or together

A synergism exists between some competitive muscle relaxants. However, maintenance requirement of a combination of muscle relaxants has been evaluated only in paediatric patients. We studied 45 elective adult surgical patients (ASA I‐II) during propofol‐alfentanyl‐N2O‐O2‐anaesthesia. The first 30 patients were randomized to receive either atracurium or vecuronium to create individual dose‐response curves for these muscle relaxants. ED95‐values for atracurium and vecuronium were 260±9 and 59±3 μg · kg‐1, respectively (mean±s.e.mean). Requirements of atracurium and vecuronium to maintain an 85–95% neuromuscular blockade were 301 and 83 μg kg‐1 h‐1, respectively. An additional 15 patients received a combination of atracurium and vecuronium (cAV) in an equipotent dose ratio. An ED95 of a cAV was 94± 7 μg · kg‐1 of atracurium together with 21±2 μg · kg‐1 of vecuronium, or 72±6% of one ED95 dose of a parent agent. Potentiation was significant (P=0.0001). A maintenance requirement of a cAV was 120 μg kg‐1 h‐1 of atracurium together with 27 μg kg‐1 h‐1 of vecuronium. Thus, a significant potentiation was maintained also during the course of anaesthesia. A cAV had an effect like one intermediate‐acting agent. If a cAV is used instead of using atracurium or vecuronium alone, the maximal reduction of drug consumption would be approximately 30%.

PERORAL TRAMADOL PREMEDICATION INCREASES POSTOPERATIVE NAUSEA AND DELAYS HOME-READINESS IN DAY-CASE KNEE ARTHROSCOPY PATIENTS

Background and Aims: To evaluate the effect of preoperative oral tramadol on postoperative pain and its effect on the patients home-readiness after diagnostic day-case knee arthroscopy performed under spinal anaesthesia. Material and Methods: We studied 156 outpatients in a prospective, randomized, double-blind fashion to examine the postoperative analgesic effect of preoperative oral slow-release tramadol. Postoperative pain was measured using a 100-mm visual analogue scale (VAS). Postoperative nausea and vomiting (PONV) and the patients home-readiness were assessed. Results: There were no statistically significant differences in the postoperative VAS scores between the tramadol and placebo groups, nor was there any significant difference in the need for postoperative pain medication. Patients in the tramadol group had higher incidence of PONV and they were discharged from hospital later than those given placebo although the tramadol patients required less intravenous midazolam for sedation. Conclusions: Preoperatively given slow-release tramadol is ineffective for reduction of postoperative pain after day-case arthroscopy of the knee. Additionally, preoperative tramadol is associated with higher incidence of PONV and it seems to cause delay in the patients home-readiness.