DOI： 10.1213/ANE.0000000000004024

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BACKGROUND: Magnesium has been investigated as an adjuvant for neuraxial anesthesia, but the effect of caudal magnesium on postoperative pain is inconsistent. The aim of this systematic review and meta-analysis was to evaluate the analgesic effect of caudal magnesium. METHODS: We searched six databases, including trial registration sites. Randomized clinical trials reporting the effect of caudal magnesium on postoperative pain after general anesthesia were eligible. The risk ratio for use of rescue analgesics after surgery was combined using a random-effects model. We also assessed adverse events. The I2 statistic was used to assess heterogeneity. We assessed risk of bias with Cochrane domains. We controlled type I and II errors due to sparse data and repetitive testing with Trial Sequential Analysis. We assessed the quality of evidence with GRADE. RESULTS: Four randomized controlled trials (247 patients) evaluated the need for rescue analgesics. In all four trials, 50 mg of magnesium was administered with caudal ropivacaine. The results suggested that the need for rescue analgesia was reduced significantly by caudal magnesium administration (risk ratio 0.45; 95% confidence interval 0.24-0.86). There was considerable heterogeneity as indicated by an I2 value of 62.5%. The Trial Sequential Analysis-adjusted confidence interval was 0.04-5.55, indicating that further trials are required. The quality of evidence was very low. The rate of adverse events was comparable between treatment groups. CONCLUSION: Caudal magnesium may reduce the need for rescue analgesia after surgery, but further randomized clinical trials with a low risk of bias and a low risk of random errors are necessary to assess the effect of caudal magnesium on postoperative pain and adverse events. TRIAL REGISTRATION: University Hospital Medical Information Network Clinical Trials Registry UMIN000025344.

DOI： 10.1371/journal.pone.0190354

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Language：English   Publisher：LIPPINCOTT WILLIAMS & WILKINS  

BACKGROUND: Caudal anesthesia has been used for postoperative pain control in pediatric surgical patients, but the duration of the analgesic effect is occasionally unsatisfactory. Intravenous steroids have been shown to be effective for postsurgical pain management after certain surgeries. The aim of this meta-analysis with trial sequential analysis (TSA) was to evaluate the analgesic effect of steroids in patients administered with caudal anesthesia.
METHODS: This study was a systematic review and meta-analysis. A search of published literature was conducted in the MEDLINE, EMBASE, Web of Science, and Cochrane Central Register of Controlled Trials databases and in trial registration sites. Randomized controlled trials that compared intravenous steroids with a placebo in pediatric patients who had received caudal anesthesia for surgery were included in the study. The primary outcomes from the present metaanalysis were the analgesic duration and the number of patients who required rescue analgesics. The analgesic duration and incidence of rescue use were summarized using mean difference or risk ratio with a 97.5% confidence interval (CI), respectively. If the 97.5% CI of the mean difference or risk ratio included a value of 0 or 1, respectively, we considered the difference not to be significant. We used the random effects model to combine the results. Heterogeneity was quantified with the I-2 statistic. The quality of the trials was evaluated using the Cochrane methodology. Moreover, a TSA with a risk of type 1 error of 2.5% and power of 90% was performed. We established the minimum clinically meaningful difference of analgesic duration as 3 hours. The target sample size for meta-analysis was also calculated in the TSA. We also assessed adverse events.
RESULTS: Six trials with 424 patients were included; 211 patients received intravenous steroids. All trials compared dexamethasone of at least 0.5 mg/kg dose with a placebo. Dexamethasone prolonged the duration of caudal analgesia (mean difference, 244 minutes; 97.5% CI, 188-300). Heterogeneity was considerable with an I-2 value of 94.8%. Quality of evidence was very low. The TSA suggested that only 17.0% of the target sample size had been reached, but the cumulative Z score crossed the trial sequential monitoring boundary to indicate a benefit. Rescue use was reported in 4 studies with 260 patients. Rescue use was not significantly reduced in the dexamethasone group (risk ratio, 0.53; 97.5% CI, 0.09-3.30; I-2, 98.7%). No increase in adverse events was reported.
CONCLUSIONS: Intravenous dexamethasone prolongs the analgesic duration of caudal anesthesia. Trials to investigate the effectiveness of a lower dose of the dexamethasone in prolonging analgesic effects would be of interest. Further trials with a low risk of bias are necessary.

DOI： 10.1213/ANE.0000000000002453

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Language：English   Publishing type：Research paper (scientific journal)  

INTRODUCTION: Unintentional catecholamine flush caused by inappropriate release of an intravenous occlusion during use of a syringe pump in the intensive care unit (ICU) can have dangerous consequences in patients receiving critical care. We investigated whether anesthesiology residents understood how to deal with syringe pump occlusion in a simulated ICU setting. METHODS: We set up a mannequin that virtually simulated a sedated patient under mechanical ventilation after cardiac surgery, with epinephrine and dopamine being infused by syringe pumps to maintain blood pressure at 100/50 mm Hg. Prior to a participant entering the simulated ICU, one of the stopcocks for the catecholamine was occluded. Thereafter, the blood pressure of the mannequin dropped to 60/30 mm Hg. If the participant inappropriately released the occlusion, resulting in a catecholamine flush, an operator immediately elevated the blood pressure to 200/100 mm Hg. In the subsequent debriefing session, the simulation facilitator evaluated whether the participant could diagnose that intravenous occlusion was the cause of hypotension in this scenario. RESULTS: Sixteen anesthesiology residents participated in the study. Only 3 of 10 participants who had previous knowledge of how such situations should be handled could appropriately release back pressure. Eleven residents released the occlusion without relieving syringe pressure. After their debriefing sessions, all the participants were of the opinion that the present simulation training was impressive and useful for them. CONCLUSIONS: Anesthesiology residents might inappropriately handle a situation of intravenous occlusion in their clinical practice. It may be necessary for the manufacturers to improve the safety features of syringe pumps.

DOI： 10.1097/PTS.0000000000000232

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：ELSEVIER SCIENCE INC  

Study objective: The glass vial of acetaminophen as an intravenous preparation (Acelio((R)), Terumo, Japan) has a strong internal negative pressure. The aim of our study was to determine if this negative pressure could result in medication administration errors if not released prior to connecting to the IV set.
Design: Questionnaire survey and simulation study.
Setting: University hospital and its affiliated hospitals.
Subjects: Fifty-two anesthesiologists in 6 different hospitals in Yokohama.
Measurements: A questionnaire on current practice was sent to the subjects. The authors then first calculated the internal pressure of the Acelio vial followed by a simulation set-up. This set-up measured the amount of saline that could be aspirated from a syringe loaded on a syringe pump connected via a secondary IV line when the Acelio vial was attached to the primary line without prior release of the internal pressure. The volume of aspiration was tested with two syringe sizes and with a fully open IV clamp vs partially closed.
Main results: Twenty-nine (56.9%) of 51 anesthesiologists who responded to the survey had connected the Acelio vial at least once without releasing the internal negative pressure, and 21 experienced consequences such as backflow of the venous blood. The pressure inside the Acelio vial was 81.8 +/- 19.6 Torr. With the clamp of the simulated IV line fully open, the amount of saline aspirated before the alarm of the syringe pump went off was 1.5 +/- 0.1 ml and 32 +/- 0.3 ml when 20 ml and 50 ml syringes were used, respectively. When the clamp was partially closed to allow 2 drops per second, this value was 1.3 +/- 0.1 ml and 2.3 +/- 0.1 ml, respectively. After removing the plunger from the holder of the syringe pump, an additional 7 ml (clamp partially closed) or 15-18 ml (clamp fully open) was aspirated in the subsequent 1 min.
Conclusions: A considerable number of anesthesiologists experienced consequences caused by the negative pressure inside the Acelio vial. This can also cause aspiration of the contents of the syringe pump. (C) 2016 Elsevier Inc. All rights reserved.

DOI： 10.1016/j.jclinane.2016.12.002

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Language：English   Publisher：FEDERATION AMER SOC EXP BIOL  

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：HINDAWI PUBLISHING CORP  

The aim of this study was to reveal the effect of anesthesiologist's mental workload during induction of general anesthesia. Twenty-two participants were categorized into anesthesiology residents (RA group, n = 13) and board certified anesthesiologists (CA group, n = 9). Subjects participated in three simulated scenarios (scenario A: baseline, scenario B: simple addition tasks, and scenario C: combination of simple addition tasks and treatment of unexpected arrhythmia). We used simple two-digit integer additions every 5 seconds as a secondary task. Four kinds of key actions were also evaluated in each scenario. In scenario C, the correct answer rate was significantly higher in the CA versus the RA group (RA: 0.370 +/- 0.050 versus CA: 0.736 +/- 0.051, P < 0.01, 95% CI -0.518 to -0.215) as was the score of key actions (RA: 2.7 +/- 1.3 versus CA: 4.0 +/- 0.00, P = 0.005). In a serious clinical situation, anesthesiologists might not be able to adequately perform both the primary and secondary tasks. This tendency is more apparent in young anesthesiologists.

DOI： 10.1155/2016/1058750

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：IOS PRESS  

BACKGROUND: An unintended bolus is delivered by the syringe pump if intravenous line occlusion is released in an inappropriate manner.
OBJECTIVE: The aim of this study was to measure the amount of flushed fluid when an occlusion is inappropriately released and to assess the effect of different syringe pump settings (flow rate, alarm setting, size of syringe and syringe pump model) on the flushed amount.
METHODS: After the stopcock was closed, infusions were started with different model syringe pumps (Terufusion (R) TE312 and TE332S), different syringe sizes or at different alarm settings. After the occlusion alarm sounded, the occlusion was released and the amount of fluid emerging from the stopcock was measured.
RESULTS: The bolus was significantly lower when the alarm was set at a low-pressure setting. The bolus was significantly lower with a 10-ml than a 50-ml syringe. A significant difference was seen only when a 50-ml syringe was used (TE312: 1.99 +/- 0.16 ml vs. TE332S: 0.674 +/- 0.116 ml, alarm High, p < 0.001).
CONCLUSION: To minimize the amount of accidentally injected medication, a smaller syringe size and a low alarm setting are important. Using a syringe pump capable of reducing the inadvertently administered bolus may be helpful.

DOI： 10.3233/THC-130754

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：LIPPINCOTT WILLIAMS & WILKINS  

Purpose of review
There are still many controversies about perioperative management of hypertensive patients. This review aims to provide relevant instruction based on evidence regarding the treatment of those patients.
Recent findings
Mild to moderate hypertension is not independently responsible for perioperative cardiac complications. The position is less clear for severely hypertensive patients. A randomized study shows no benefit of the traditional practice of delaying elective surgery in severely hypertensive patients until better control of blood pressure is achieved. Perioperative use of beta-blockers or alpha-2 agonists has been shown to maintain perioperative hemodynamic stability and thereby to prevent major cardiac complications.
Summary
Delaying surgery only for the purpose of blood pressure control may not be necessary, especially in the case of mild to moderate hypertension. Strict care, however, should be taken to ensure perioperative hemodynamic stability because labile hemodynamics, rather than preoperative hypertension per se, appears to be more closely associated with adverse cardiovascular complications. Delaying surgery in hypertensive patients may be justified if target organ damage exists that can be improved by such a delay or if (suspected) target organ damage should be evaluated further before the operation.

DOI： 10.1097/01.aco.0000192811.56161.23

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DOI： 10.1097/00004311-200404240-00010

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Language：Japanese   Publisher：(株)学研メディカル秀潤社  

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Language：Japanese   Publisher：日本臨床麻酔学会  

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Language：Japanese   Publisher：神奈川県医師会  

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Language：Japanese   Publisher：(一社)日本心臓血管麻酔学会  

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Language：Japanese   Publisher：(株)メディカル・サイエンス・インターナショナル  

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Language：Japanese   Publisher：(株)メディカル・サイエンス・インターナショナル  

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Language：Japanese  

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Language：English   Publisher：Lippincott Williams and Wilkins  

Background: Although more than 30 yr ago the minimum alveolar concentration (MAC) of xenon was determined to be 71%, that previous study had technological limitations, and no other studies have confirmed the MAC value of xenon since. The current study was designed to confirm the MAC value of xenon in adult surgical patients using more modern techniques. Methods: Sixty patients were anesthetized with sevoflurane with or without xenon. They were randomly allocated to one of four groups
patients in group 1 received no xenon, whereas those in groups 2, 3, and 4 received end-tidal concentrations of 20, 40, and 60%, respectively (n = 15 each group). Target end-tidal sevoflurane concentrations were chosen using the "up-and-down" method in each group. After steady state sevoflurane and xenon concentrations were maintained for at least 15 min, each patient was monitored for a somatic response at surgical incision. Somatic response was defined as any purposeful bodily movement. The MAC of sevoflurane and its reduction by xenon was evaluated using the multiple independent variable logistic regression model. Results: The interaction coefficient of the multiple variable logistic regression was not significantly different from zero (P = 0.143). The MAC of xenon calculated as xenon concentration that would reduce MAC of sevoflurane to 0% was 63.1%. Conclusions: The authors could not determine whether interaction in blocking somatic responses in 50% of patients is additive. The MAC of xenon is in the range of the values that were predicted in a previous study.

DOI： 10.1097/00000542-200104000-00014

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Language：English   Publisher：Lippincott Williams and Wilkins  

Background: Although anesthesia with xenon has been supplemented with fentanyl, its requirement has not been established. This study was conducted to determine the plasma concentrations of fentanyl necessary to suppress somatic and hemodynamic responses to surgical incision in 50% patients in the presence of 0.7 minimum alveolar concentration (MAC) xenon. Methods: Twenty- five patients were allocated randomly to predetermined fentanyl concentration between 0.5 and 4.0 ng/ml during 0.7 MAC xenon anesthesia. Fentanyl was administered using a pharmacokinetic model-driven computer-assisted continuous infusion device. At surgical incision each patient was monitored for somatic and hemodynamic responses. A somatic response was defined as any purposeful bodily movement. A positive hemodynamic response was defined as a more than 15% increase in heart rate or mean arterial pressure more than the preincision value. The concentrations of fentanyl to prevent somatic and hemodynamic responses in 50% of patients were calculated using logistic regression. Results: The concentration of fentanyl to prevent a somatic response to skin incision in 50% of patients in the presence of 0.7 MAC xenon was 0.72 ± 0.07 ng/ml and to prevent a hemodynamic response was 0.94 ± 0.06 ng/ml. Conclusions: Comparing these results with previously published results in the presence of 70% nitrous oxide, the fentanyl requirement in xenon anesthesia is smaller than that in the equianesthetic nitrous oxide anesthesia.

DOI： 10.1097/00000542-200004000-00022

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