Peter R. Freund

Hemodynamic response and change in organ blood volume during spinal anesthesia in elderly men with cardiac disease

Aging and disease may make the elderly patient with cardiac disease particularly susceptible to hypotension during spinal anesthesia.We studied 15 men, 59-80 y old, with histories of prior myocardial infarction (n = 9), congestive heart failure (n = 2), and/or stable myocardial ischemia (n = 11) given spinal anesthesia with 50 mg lidocaine in dextrose. Technetium-99m-labeled red blood cell imaging estimated left ventricular ejection fraction (EF) and changes in blood volume in the abdominal organs and legs. Arterial and pulmonary artery catheters provided hemodynamic measurements. Sensory block averaged T4 (range T1-10). Mean arterial pressure decreased 33% +/- 15% (SD) (P < 0.001), secondary to decreases in vascular resistance (SVR), -26% +/- 13% (P < 0.001) and cardiac output, -10% +/- 16% (P = 0.03). EF increased from 53% +/- 11% to 58% +/- 14% (P < 0.001) while left ventricular end-diastolic volume (LVEDV) decreased (-19% +/- 9%, P < 0.001). Blood volume increased in the legs (6% +/- 6%, P = 0.006), kidneys (10% +/- 9%, P < 0.001), and mesentery (7% +/- 5%, P 0.001) but not in the liver or spleen. Cardiac function was well maintained. We concluded that the primary mechanism of hypotension was a decrease in SVR, not cardiac output, despite the decrease in LVEDV. (Anesth Analg 1997;85:99-105)

The effect of bispectral index monitoring on end-tidal gas concentration and recovery duration after outpatient anesthesia

We performed this study to determine whether instituting monitoring of bispectral index (BIS) throughout an entire operating room would affect end-tidal gas concentration (as a surrogate for anesthetic use) or speed of recovery after outpatient surgery. Primary caregivers (n = 69) were randomly assigned to a BIS or non-BIS Control group with cross-over at 1-mo intervals for 7 mo. Data were obtained in all outpatients except for those having head-and-neck surgery. Mean end-tidal gas concentration and total recovery duration were compared by unpaired t-test. Overall, 469 patients (80%) received propofol for induction and sevoflurane for maintenance. This homogeneous group was selected for statistical analysis. Mean end-tidal sevoflurane concentration was 13% less in the BIS group (BIS, 1.23%; Control, 1.41%;P < 0.0001); differences were most evident when anesthesia was administered by first-year trainees. Mean BIS values were 47 in the BIS-Monitored group. Total recovery was 19 min less with BIS monitoring in men (BIS group, 147 min; Controls, 166 min;P = 0.035), but not different in women. We conclude that routine application of BIS monitoring is associated with a modest reduction in end-tidal sevoflurane concentration. In men, this may correlate with a similar reduction (11%) in recovery duration.

Trends in quality of anesthesia care associated with changing staffing patterns, productivity, and concurrency of case supervision in a teaching hospital.

BACKGROUND The authors used continuous quality improvement (CQI) program data to investigate trends in quality of anesthesia care associated with changing staffing patterns in a university hospital. METHODS The monthly proportion of cases performed by solo attending anesthesiologists versus attending-resident teams or attending-certified registered nurse anesthetist (CRNA) teams was used to measure staffing patterns. Anesthesia team productivity was measured as mean monthly surgical anesthesia hours billed per attending anesthesiologist per clinical day. Supervisory ratios (concurrency) were measured as mean monthly number of cases supervised concurrently by attending anesthesiologists. Quality of anesthesia care was measured as monthly rates of critical incidents, patient injury, escalation of care, operational inefficiencies, and human errors per 10,000 cases. Trends in quality at increasing productivity and concurrency levels from 1992 to 1997 were analyzed by the one-sided Jonckheere-Terpstra test. RESULTS Productivity was positively correlated with concurrency (r = 0.838; P<0.001). Productivity levels ranged from 10 to 17 h per anesthesiologist per clinical day. Concurrency ranged from 1.6 to 2.2 cases per attending anesthesiologist. At higher productivity and concurrency levels, solo anesthesiologists conducted a smaller percentage of cases, and the proportion of cases with CRNA team members increased. The patient injury rate decreased with increased productivity levels (P = 0.002), whereas the critical incident rate increased (P = 0.001). Changes in operational inefficiency, escalation of care, and human error rates were not statistically significant (P = 0.072, 0.345, 0.320, respectively). CONCLUSIONS Most aspects of quality of anesthesia care were apparently not effected by changing anesthesia team composition or increased productivity and concurrency. Only team performance was measured; the role of individuals (attending anesthesiologist, resident, or CRNA) in quality of care was not directly measured. Further research is needed to explain lower patient injury rates and increases in critical incident reporting at higher concurrency and productivity levels.

Effects of bispectral index monitoring on recovery from surgical anesthesia in 1,580 inpatients from an academic medical center.

Background:The purpose of this study was to determine whether monitoring Bispectral Index (BIS) would affect recovery parameters in patients undergoing inpatient surgery. Methods:Anesthesia providers (n = 69) were randomly assigned to one of two groups, a BIS or non-BIS control group. A randomized crossover design was used, with reassignment at monthly intervals for 7 months. Duration of time in the postanesthesia care unit, time from the end of surgery to leaving the operating room, and incidence of delayed recovery (> 50 min in recovery) were compared in patients treated intraoperatively with or without BIS monitoring. Data were analyzed by analysis of variance, unpaired t test, or chi-square test as appropriate. Results:One thousand five hundred eighty patients in an academic medical center were studied. The mean BIS in the monitored group was 47. No differences were found in recovery parameters between the BIS-monitored group and the control group when comparisons were made using all subjects or when data were analyzed within anesthetic subgroups stratified by anesthetic agent or duration of anesthesia. There were some small reductions in the intraoperative concentration of sevoflurane (but not isoflurane). Conclusions:The use of BIS monitoring for inpatients undergoing a wide variety of surgical procedures in an academic medical center had some minor effects on intraoperative anesthetic use but had no impact on recovery parameters.

A prospective study of intraoperative pulse oximetry failure

Since pulse oximetry is now an ASA standard for intraoperative monitoring, we sought to determine the intraoperative failure rate for this device. We prospectively evaluated the intraoperative failure rate of our pulse oximeters at the four University of Washington Hospitals (University of Washington Medical Center, Veterans Affairs Medical Center [VAMC], Childrens Hospital and Medical Center, and Harborview Medical Center [HMC]) recorded from April 1989 to August 1989. We defined failure as the inability to obtain any oximetry reading for a cumulative period of more than 30 minutes during any anesthetic procedure after all equipment malfunctions had been eliminated. Our pulse oximeters failed in 124 of 11,046 cases studied; this is a failure rate of 1.12%, which ranged from 0.56% at HMC to 4.24% at VAMC. The failure rate at VAMC (4.24%) was significantly higher than the other hospitals (p<0.001). Those cases associated with the pulse oximeter failure had the following characteristics: (1) an ASA status of 3 or higher, (2) lengthy operations, and (3) elderly patients. When the device did fail in a patient, it did not function for 32% of the mean anesthesia time. We conclude that the intraoperative use of the pulse oximetry can provide information about blood oxygen saturation in most patients. However, in approximately 1% of the patients we studied in the operating room, mechanically functioning pulse oximeters failed to provide readings of blood oxygen saturations during routine operative use.

Propranolol reduces bupivacaine clearance

Propranolol reduces the clearance of lidocaine by both reducing hepatic blood flow and inhibiting lidocaine metabolism. The authors investigated the possibility that propranolol reduces the clearance of bupivacaine as well. Bupivacaine, 30-50 mg, was administered intravenously to six normal human volunteers, over 10-15 min on two occasions, at least 2 weeks apart. Propranolol, 40 mg orally every 6 h, was used on one occasion, beginning 24 h prior to the bupivacaine administration. The sequence of the sessions was randomized. Twenty-two venous blood samples were obtained over 36 h in order to determine bupivacaine clearance, terminal elimination rate constant, and volume of distribution. All subjects experienced mild CNS toxicity, consisting of tinnitus, facial tingling, or subtle visual disturbances, associated with peak venous plasma concentrations of 0.81 to 2.7 micrograms/ml. Mean bupivacaine clearance was 0.33 +/- 0.12 l/min for the control session and 0.21 +/- 0.12 l/min during propranolol use, a significant 35% reduction (P less than 0.01). The terminal elimination rate constant (beta) was 0.27 +/- 0.16 h-1 for the control session and 0.14 +/- 0.069 h-1 with propranolol (P less than 0.05); terminal elimination half-lives were 2.6 and 4.9 h, respectively. Volume of distribution was unchanged. Because bupivacaine clearance should be relatively insensitive to hepatic perfusion, it appeared that propranolol caused a substantial inhibition of bupivacaine metabolism at the level of the hepatocyte. These data suggest that concomitant use of propranolol could result in the accumulation of a toxic concentration of bupivacaine.

Cost-effective Reduction of Neuromuscular-blocking Drug Expenditures

Background: Anesthetic drug expenditures have been a focus of cost‐containment efforts. The aim of this study was to determine whether expenditures for neuromuscular‐blocking agents could be reduced without compromising outcome, and to determine whether such a cost‐effective pattern of neuromuscular blocker use could be sustained. Methods: Education, practice guidelines, and paperwork barriers were used to persuade anesthesiologists to substitute low‐cost neuromuscular‐blocking drugs (pancuronium or a metocurine‐pancuronium combination) for a more costly neuromuscular‐blocking drug (vecuronium). Neuromuscular‐blocking drug use in all patients during a historical control period (6 months; n = 4,804) was compared with that during two consecutive 1‐yr periods of intervention (n = 9,761/n = 10,695). Expenditures for vecuronium and for all neuromuscular‐blocking drugs were compared for the control and intervention periods. The rate of complications related to neuromuscular‐blocking drugs was determined by an ongoing continuous quality improvement program. Results: Vecuronium use decreased by 76% during the first and second yr of intervention, compared with the historical period (P <0.01). The cost of neuromuscular‐blocking drugs decreased by 31% (P <0.01) and 47% (P < 0.01) for the first and second yr, respectively. The complication rate related to neuromuscular‐blocking drugs was 0.081% in the historical period and 0.11% and 0.093% during the intervention periods (P = 0.29 and 0.41). Conclusion: Practice guidelines, education, and paperwork barriers used together substantially reduced the expenditures for neuromuscular‐blocking drugs for 2 yr without adversely affecting clinical outcome.

Caudal anesthesia with lidocaine or bupivacaine: plasma local anesthetic concentration and extent of sensory spread in old and young patients.

Continuous caudal peridural anesthesia with 2% lidocaine (6 mg/kg) or 0.75% bupivacaine (2.2 mg/kg), both with epinephrine 1:200,000, was studied in two groups of male patients, younger than 40 or older than 55 yr old, respectively. Patients receiving lidocaine in the younger group (n = 6) were 32 ± 5.2 (mean ± SD) yr old and weighed 75 ± 12 kg, while those in the older group (n = 16) were 66 ± 5.3 yr old and weighed 72 ± 8.2 kg. Patients receiving bupivacaine in the respective groups were 27 ± 7.0 yr old (n = 5), and 76 ± 10 kg compared to 69 ± 10 yr (n = 14) and 75 ± 10 kg. Anesthesia was satisfactory in all patients. Extent of sensory anesthesia, peak plasma lidocaine or bupivacaine concentrations, and area under the plasma concentration-time curves were independent of age. No local anesthetic toxicity was observed and peak drug concentrations were below those commonly associated with toxicity.

Effect of spontaneous sighs on arterial oxygenation during isoflurane anesthesia in humans

: The presence, frequency, and volume of spontaneous sighs was evaluated in 21 (ASA 1-2) supine patients aged 44 +/- 15.2 (SD) yr, during isoflurane-nitrous oxide anesthesia. Before induction the inspiratory capacity of each patient was determined. After induction of anesthesia and tracheal intubation patients breathed spontaneously except for three manual inflations to each patients predetermined inspiratory capacity at the beginning and end of surgery. Arterial blood gas tensions were measured before and 5 min after each set of mechanical deep breaths and each hour during surgery, the mean duration of which was 2 +/- 0.09 hr. Spontaneous sighs occurred in 13 of 21 patients. The average frequency was 6 +/- 4 sighs/hr. At FIO2 = 0.5, nonsighing patients had an initial PaO2 of 229 +/- 59 mm Hg and sighers had an initial PaO2 of 162 +/- 57 mm Hg (P less than 0.05). Arterial oxygen did not change in sighing patients during the course of surgery, while in nonsighing patients the PaO2 decreased from the initial value of 229 +/- 60 mm Hg to 170 +/- 63 mm Hg (P less than 0.05). Mechanical deep breaths administered at the end of surgery produced no improvement in oxygenation in either sighers or nonsighers. The presence or absence of sighs did not correlate with PaO2 or PACO2. Though the results suggest that spontaneous sighs in some patients may function to help maintain arterial oxygenation, all patients maintained their PaO2 while breathing spontaneously under general anesthesia in the supine position.

An Aid to Learning to Use the Fiberoptic Bronchoscope for Intubation

In summary, the benefit of epidural versus intravenous fentanyl administration for postoperative analgesia remains controversial, and the reasons for the contradictory results found in the literature are not clear. The small number of patients entering each study may be viewed as a limitation to a generalization of their results. Traditional reviews may be subjected to the idiosyncratic impressions of the reviewer (7). A systematic review of the literature and a meta analysis may provide an improved reflection of reality (8) and should be performed to shed some light on this topic.