alpha(2)-adrenergic agonists for regional anesthesia - A clinical review of clonidine (1984-1995)

Sequential design methods for binary response variables exist for determination of the concentration or dose associated with the 50% point along the dose-response curve; the up-and-down method of Dixon and Mood is now commonly used in anesthesia research. There have been important developments in statistical methods that (1) allow the design of experiments for the measurement of the response at any point (quantile) along the dose-response curve, (2) demonstrate the risk of certain statistical methods commonly used in literature reports, (3) allow the estimation of the concentration or dose-the target dose-associated with the chosen quantile without the assumption of the symmetry of the tolerance distribution, and (4) set bounds on the probability of response at this target dose. This article details these developments, briefly surveys current use of the up-and-down method in anesthesia research, reanalyzes published reports using the up-and-down method for the study of the epidural relief of pain during labor, and discusses appropriate inferences from up-and-down method studies.

Advances in and limitations of up-and-down methodology: a précis of clinical use, study design, and dose estimation in anesthesia research.

Propofol is an intravenous sedative hypnotic agent which rapidly and reliably causes loss of consciousness. It is also associated with a quick and 'smooth' recovery, which distinguishes it from many of the more traditional anaesthetic regimens. Like other intravenous agents, propofol is both a cardiovascular and a respiratory depressant; however, the risk of these effects can be lessened by appropriate dosage adjustment or patient management. Anaphylaxis with propofol is rare. Propofol anaesthesia in day case surgery is consistently associated with a quicker early recovery than other intravenous agents and the more traditional anaesthetic regimens. Savings in time to discharge were more variable compared with these regimens, although propofol was commonly associated with less post-operative nausea and vomiting in this period. In the future, the relative benefits of propofol compared with the newer volatile agents (desflurane and sevoflurane) and propofol/volatile agent combinations need to be examined in this clinical setting. There is now clinical experience with propofol in major surgical procedures including cardiac and neurosurgery. Propofol has also been investigated as a sedative accompanying regional or local anaesthesia for diagnostic and therapeutic procedures, and in other clinical settings (ophthalmic surgery, cardioversion and electroconvulsive therapy). The unique antiemetic, antiepileptic and antipruritic effects of propofol may further broaden its appeal. As a result of its favourable recovery profile, propofol holds a central place in day case surgery anaesthesia. Accumulating clinical experience in cardiac and neurosurgery suggests that the full potential of propofol has yet to be realised.

Propofol. An update of its use in anaesthesia and conscious sedation.

Advances in perioperative anesthesia and analgesia have improved pain relief and satisfaction in surgical patients. Opioid administered via patient-controlled analgesia (IV-PCA) provides better analgesia and patient satisfaction than conventional delivery. However, IV-PCA has not been demonstrated to affect postoperative outcome significantly. Recent studies suggest that advances in anesthesia and postoperative analgesia can affect postoperative outcome.1–3 Epidural anesthesia and analgesia have the potential to reduce or eliminate the perioperative physiologic stress responses to surgery and thereby decrease surgical complications and improve outcomes.1–3 The purposes of this review are to integrate experimental and clinical data addressing the physiologic effects of epidural anesthesia and postoperative epidural analgesia on surgical patients and to review the real and potential benefits of this technology with respect to patient outcomes. The effects of epidural anesthesia and analgesia on cardiovascular, coagulation, pulmonary, and gastrointestinal physiology; the surgical stress response; immune function; cognition; complications; and surgical outcomes will be reviewed separately.

The Role of Epidural Anesthesia and Analgesia in Surgical Practice

BACKGROUND:A recent meta-analysis showed that compared with general anesthesia (GA), neuraxial block reduced many serious complications in patients undergoing various types of surgeries. It is not known whether this finding from studying heterogeneous patient groups is applicable to a particular sur

A comparison of neuraxial block versus general anesthesia for elective total hip replacement : A meta-analysis

Twenty-eight elderly patients scheduled for urological surgery were randomly assigned to receive, in a double-blind study, subarachnoid hyperbaric bupivacaine 15 mg with 50 micrograms (group A, n = 7), 25 micrograms (group B, n = 7), or 12.5 micrograms (group C, n = 7) of fentanyl or 1 ml of saline (group D, n = 7) in a total volume of 4 ml. The pattern of breathing and the ventilatory response to CO2 were studied before and 90, 150 and 480 min after the subarachnoid injection. In group A, mild pruritus and sedation occurred in five patients, while nausea, vomiting and periodic breathing occurred in two. In group B, mild pruritus and sedation were observed in four patients, while nausea and vomiting occurred in two. No significant differences in minute ventilation, respiratory drive and respiratory timing were observed between the groups. Patients receiving fentanyl 50 micrograms showed a percentual change from baseline values as function of time (slope VE/PE'CO2) significantly below baseline at 90 and 150 min (p less than 0.05). However, the baseline values in this group reverted after 480 min. No side effects were observed in groups C or D. It is concluded that subarachnoid fentanyl 50 micrograms can cause an early respiratory depression and its use as a postoperative analgesic should be avoided in the elderly.

Ventilatory effects of subarachnoid fentanyl in the elderly.

Which induction drug for cesarean section? a comparison of thiopental sodium, propofol, and midazolam

Frequency of hypotension and bradycardia during general anesthesia, epidural anesthesia, or integrated epidural-general anesthesia for total hip replacement.

Ninety patients aged 56-85 years scheduled for suprapubic prostatectomy, randomly received intrathecally either bupivacaine 30 mg (group A, n = 30), bupivacaine 30 mg plus buprenorphine 0.03 mg (group B, n = 30) or bupivacaine 30 mg plus buprenorphine 0.045 mg (group C, n = 30). Prolonged postoperative analgesia, minimal disturbance of consciousness and comfortable breathing were common to the groups that received buprenorphine. The higher concentration of buprenorphine improved the quality and duration of analgesia. The only side effects found in the buprenorphine groups were nausea and vomiting in 11 and 14 patients, respectively, in groups B and C. Our study shows that buprenorphine is an effective analgesic, suitable for the management of postoperative pain in elderly patients.

https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/pdf/10.1111/j.1365-2044.1988.tb05482.x

Intrathecal buprenorphine for postoperative analgesia in the elderly patient.

Ninety-five healthy nulliparous women, ASA physical status I–II with an uncomplicated pregnancy and single fetus in vertex position were given lumbar epidural analgesia. Patients in Group A (n = 35) received bupivacaine 0.125 per cent with epinephrine 1800.000; Groups B (n = 30) and C (n = 30) received the same agents as Group A but with the addition to the initial dose of 50 or 100 µg of fentanyl respectively. All patients were evaluated for duration and quality of analgesia, duration of labour, method of delivery and total dose of bupivacaine used. The addition of either 50 or 100 µg of fentanyl resulted in longer duration of analgesia (93 ± 9 min and 106 ± 8 min respectively vs 55 ± 7) and reduced bupivacaine total doses (64 ± 0.03 and 55 ± 1.5 respectively vs 109.5 ± 1.3). Only the addition of 100 µg of fentanyl improved significantly the quality of analgesia (43.3 per cent of excellent scores vs 6.6 per cent in Group B and 5.7 per cent in Group A). Addition of fentanyl did not affect the duration of labour, the method of delivery and the neonatal neurobehaviour scores.

/pdf/epidural-fentanyl-plus-bupivacaine-0-125-per-cent-for-labour-3nyjb67ple.pdf

Epidural fentanyl plus bupivacaine 0.125 per cent for labour: analgesic effects.

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