Acta anaesthesiologica Taiwanica : official journal of the Taiwan Society of Anesthesiologists最新文献

An increasing body of evidence shows that the choice of anesthetic can strongly influence more than simply the quality of anesthesia. Regional and general anesthesia have often been compared to ascertain whether one provides benefits through dampening the stress response or harms by accelerating cancer progression. Regional anesthesia offers considerable advantages, by suppressing cortisol and catecholamine levels and reducing muscle breakdown postoperatively. It also has less immunosuppressive effect and potentially reduces the proinflammatory cytokine response. As such, vital organ functions (e.g., brain and kidney) may be better preserved with regional anesthetics, however, further study is needed. Volatile general anesthetics appear to promote cancer malignancy in comparison to regional and intravenous general anesthetics, and reduce the body's ability to act against cancer cells by suppression of natural killer cell activity. There is not sufficient evidence to support an alteration of current clinical practice, however, further research into this area is warranted due to the potential implications elicited by current studies.

Objective

This randomized, double-blind study was conducted to evaluate the effect of gabapentin pretreatment on the hemodynamic response to laryngoscopy and endotracheal intubation (LETI) in treated hypertensive patients undergoing surgery.

Methods

A total of 100 controlled hypertensive patients aged 35–60 years, undergoing elective surgery under general anesthesia with endotracheal intubation, were randomly allocated into three groups. Group 1 patients received placebo at night and 2 hours prior to induction of anesthesia. Group 2 patients received placebo at night and 800 mg gabapentin 2 hours prior to induction of anesthesia. Group 3 patients received 800 mg gabapentin at night and 2 hours prior to induction of anesthesia. Anesthesia was induced with thiopentone, fentanyl, and vecuronium and maintained with isoflurane in oxygen and nitrous oxide. Patients' heart rate (HR), blood pressure (BP), and electrocardiography (ECG) changes were recorded prior to induction, after induction, and at 0 minutes, 1 minute, 3 minutes, 5 minutes, and 10 minutes after intubation. Any episodes of hypotension, bradycardia, tachycardia, hypertension, arrhythmia, and ST-T wave changes were recorded and treated accordingly.

Results

The HR was comparable among groups, with a transient rise just after intubation, followed by a gradual fall thereafter at 3 minutes, 5 minutes, and 10 minutes compared with baseline. A significant increase in BP after intubation was reported in Group 1 but not in Group 2 and Group 3. The mean arterial pressure (MAP) was significantly higher in Group 1 at 0 minute, 1 minute and 3 minutes postintubation as compared with Group 2 and Group 3 (p = 0.014). Three patients in Group 1, four patients in Group 2, and 10 patients in Group 3 developed hypotension and were treated with ephedrine, whereas five patients in Group 1 and one patient in Group 2 had hypertension after tracheal intubation. There was no significant difference between the groups with respect to the number of patients who received ephedrine boluses and in whom isoflurane had to be increased due to hypertension. No episode of bradycardia, tachycardia, dysrhythmia, or ST-T wave changes was reported.

Conclusion

Gabapentin 800 mg in a single or double dose was equally effective in attenuating the hypertensive response to laryngoscopy and tracheal intubation in treated hypertensive patients.

Objective

This study was aimed to explore the pharmacoepidemiology of chronic noncancer pain (CNCP) patients who required chronic opioid therapy (COT) in the Taiwanese population.

Methods

Using the Taiwan National Health Insurance Research Database during 2008–2009, COT-requiring CNCP patients were identified by the inclusion criteria of both chronic analgesic requirement for > 3 months per year and long-term use of controlled opioids for > 28 therapeutic days during any 3-month period in ambulatory visits with malignancy-related pain excluded. Their demographic data and pharmacoepidemiological characteristics of opioid consumption and opioid prescriptions issued in ambulatory visits were analyzed.

Results

In total, 159 patients were enrolled as COT-requiring CNCP patients, and the prevalence was calculated at 0.016% in a 2-year period. Females were outnumbered by males (45.3% vs. 54.7%). Almost 60% of them were of working age and 93.7% belonged to low-income households, as in the health insurance claims, probably implying socioeconomic disadvantages associated with CNCP. The leading three diagnoses were unspecified myalgia and myositis, lumbago, and abdominal pain of unspecified site. The most common department from where these 159 CNCP patients obtained their opioid prescriptions was the emergency department (27.6%), ensued by a pain clinic (25.3%), but they could acquire only a few opioid therapeutic days through emergency department visits. Moreover, pain clinic satisfied the majority of opioid therapeutic days. Among all opioids, morphine was the most frequently prescribed in opioid-obtaining ambulatory visits, accounting for most of the opioid therapeutic days as well as opioid consumption.

Conclusion

COT-requiring CNCP patients were easily associated with adverse socioeconomic liabilities and often visited emergency department as well as pain clinics. Morphine was the main opioid used for their chronic pain. Transfer of COT-requiring CNCP patients to appropriate departments is strongly recommended for efficient long-term pharmacotherapy for their chronic pain.

Acute and chronic subdural hemorrhage in a 33 year old woman with severe headache from occipital to frontal regions and dull neck pain was diagnosed on magnetic resonance image, which revealed cerebrospinal fluid leakage at C2–3 with spontaneous intracranial hypotension. Successful treatment was performed by epidural blood patch from the level of T7–T8 with injection of 20 mL of autologous blood.

Objectives

Currently there are no reports of the effect of increasing heart rate (HR) induced by intravenous atropine on stroke volume variation (SVV). We hypothesized that increasing HR alters the value of SVV. This prospective study aimed to investigate changes in SVV values by increasing HR induced by intravenous atropine in patients with good cardiac function. We also re-evaluated the effect of intravenous atropine alone on hemodynamics including new hemodynamic parameters such as SVV.

Methods

Patients were chosen as participants of this study if, 30 minutes after anesthesia induction, HR was below 65 beats/min. Baseline hemodynamic values were recorded, and then the patients received intravenous atropine (0.01 mg/kg; max 0.5 mg). These values were recorded again after intravenous atropine every minute for 5 minutes.

Results

Ten American Society of Anesthesiologists (ASA) physical status I–II patients aged 37–65 years who were scheduled for elective surgery were included. Intravenous atropine significantly increased HR at the 1–5 minute time points, mean arterial pressure at the 1–4 minute time points, and cardiac output at the 1–3 minute time points compared with baseline values but did not significantly change SVV, stroke volume index, pressure of end-tidal CO₂, and systemic vascular resistance.

Conclusion

Administration of intravenous atropine did not change SVV, and we present this as a novel finding.

Objectives

We have previously shown that vasopressin could inhibit the upregulation of inflammatory mediators. Expression of inflammatory mediators is tightly regulated by the upstream transcriptional pathway mitogen-activated protein kinases (MAPKs) and activated protein-1 (AP-1). In this study, we elucidated whether vasopressin could inhibit the upregulation of MAPKs/AP-1.

Methods

Murine macrophages (RAW264.7 cells) randomly received lipopolysaccharide (LPS; 100 ng/mL) or LPS plus vasopressin (1000 pg/mL) (designated as the LPS and the LPS+V groups, respectively). Control groups were run simultaneously. For MAPKs, cells were harvested at 0 minutes, 15 minutes, 30 minutes, 45 minutes, and 60 minutes after reaction. For AP-1, cells were harvested at 60 minutes after reaction. Between-group differences in MAPKs (i.e., extracellular regulated kinase, c-Jun N-terminal kinase, and p38 MAPK) and AP-1 expressions were compared.

Results

Immunoblotting assay data revealed that extracellular regulated kinase concentrations of the LPS +V group that harvested at 45 minutes and 60 minutes, but not at 15 minutes and 30 minutes, were significantly lower than those of the LPS group (p = 0.005 and p = 0.013). C-Jun N-terminal kinase concentrations of the LPS+V group that harvested at 15 minutes, 30 minutes, 45 minutes, and 60 minutes were also significantly lower than those of the LPS group (all p < 0.001). Concentrations of p38 MAPK of the LPS+V group that harvested at 15 minutes, 30 minutes, and 45 minutes, but not at 60 minutes, were also significantly lower than those of the LPS group (all p < 0.001). In addition, immunohistochemistry assay revealed that the AP-1 fluorescence signals of the LPS+V group were weaker than those of the LPS group.

Conclusion

Vasopressin inhibits MAPKs and AP-1 in endotoxin-activated macrophages.

Surgical procedures require general anesthesia using combinations of drugs including fentanyl and/or lidocaine. Because many of these drugs have bimodal anticonvulsant/proconvulsant effects, they must be administered carefully. We herein report a case of seizure attack during anesthesia induction with low-dose fentanyl and lidocaine in a young child with no history of seizures. A 10-year-old girl was scheduled to receive an elective tenectomy. After a few seconds of fentanyl and lidocaine administration for anesthesia induction, she developed generalized tonic–clonic seizures. Seizures subsided spontaneously after 3 minutes. The patient's blood sugar, serum electrolytes, and arterial blood gas analysis were normal immediately after the event. She remained hemodynamically stable; however, the surgery was postponed after communication and discussion with the surgeon. Postoperatively, there was no evidence of postictal phase, and serum electrolytes and magnetic resonance imaging of the brain were normal. The patient had an uneventful recovery. However, electroencephalogram showed that hyperventilation stimulation test induced isolated epileptiform spikes over O1, suggesting a potential paroxysmal disorder over the left occipital area. This report is on a rare complication likely caused by fentanyl or lidocaine, which suggests that these drugs should be used cautiously in children whose clinical epileptic activities have been verified or are strongly suspected.

Pain management is typically more developed in western countries compared to Asia. From the accreditation standard of the Joint Commission International (JCI), there is a broad scope for pain management. In 2008, our medical center established the pain management policy, and the goal is to be a pain-free medical facility. The Framework of Pain Management Policy including: 1. the rights of patients and family members 2. Employee education 3. Assessment of pain (screening, evaluating, monitoring) 4. Patient care of pain.

After implementation of pain management program, the compliance of pain assessment, the analysis of pain score before and after pain management and the analysis of Pain Management Index (PMI), all showed improvement in pain management program. The consumption of opioids usage steadily increased from 2010 to 2014. The success of our pain management program implementation could be attributed to the clear pain management policy, the firm support of higher leadership, the cooperation of IT department, and the quality control.