Inadvertent epidural administration of metaraminol.
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Aged↗
Biomedical subjects
C Beattie
Publications and source records attributed to C Beattie.
A modified nasal trumpet to facilitate fibreoptic intubation.
BACKGROUND: The modified nasal trumpet (MNT) is a standard nasopharyngeal airway with an added distal fenestration and fitted with a 15 mm adaptor to permit connection to an anaesthesia circuit. METHODS: Based on its successful use as an emergency device in the 'cannot intubate, cannot ventilate' scenario, we considered that the MNT would aid fibreoptic intubation by providing a patent airway, spontaneous ventilation, and inhalation anaesthesia during the procedure. We report use of the MNT for this purpose seven times in six patients with difficult airways. RESULTS: In each case, the MNT allowed oxygenation and general anaesthesia while maintaining spontaneous ventilation when awake intubation was unsuccessful or not possible. CONCLUSION: The MNT has a place in the operating room suites as a useful airway management device.
Adult↗
Progress with implementing local air-quality management in rural areas of England.
Air quality in the UK, although vastly improved from the smogs of the 1950s, now faces a new set of challenges from a variety of sources and pollutants. Poor air quality has long been associated with urban areas, but it is becoming clear that many rural locations also have locations likely to exceed the UK Air Quality Strategy-objectives: This paper will examine the extent to which rural authorities have been engaged in the local air-quality management (LAQM) process, a new regime by which air quality control is being accomplished in the UK. Results are presented from a questionnaire survey of environmental health officers of 100 rural authorities undertaken in January 1999. The paper investigates both the technical aspects of the LAQM process as well as the management approaches. The current progress of rural authorities, and some of the problems they face, are discussed particularly in comparison with urban areas. It is concluded that some rural authorities with air pollution problems stemming either from within or outwith their borough, may face significant challenges from the LAQM review and assessment process, particularly where air pollution responsibilities have only relatively recently been addressed. Rural authorities seem to be embracing these new responsibilities enthusiastically, but it is almost inevitable that they will be trailing behind urban authorities who have several decades of experience and joint working to draw upon.
Air Pollutants↗
Comparison of two different temperature maintenance strategies during open abdominal surgery: upper body forced-air warming versus whole body water garment.
BACKGROUND: A new system has been developed that circulates warm water through a whole body garment worn by the patient during surgery. In this study the authors compared two different strategies for the maintenance of intraoperative normothermia. One strategy used a new water garment warming system that permitted active warming of both the upper and lower extremities and the back. The other strategy used a single (upper body) forced-air warming system. METHODS: In this prospective, randomized study, 53 adult patients were enrolled in one of two intraoperative temperature management groups during open abdominal surgery with general anesthesia. The water-garment group (n = 25) received warming with a body temperature (rectal) set point of 36.8 degrees C. The forced-air-warmer group (n = 28) received routine warming therapy using upper body forced-air warming system (set on high). The ambient temperature in the operating room was maintained constant at approximately 20 degrees C. Rectal, distal esophageal, tympanic, forearm, and fingertip temperatures were recorded perioperatively and during 2 h after surgery. Extubated patients in both groups were assessed postoperatively for shivering, use of additional warming devices, and subjective thermal comfort. RESULTS: The mean rectal and esophageal temperatures at incision, 1 h after incision, at skin closure, and immediately postoperatively were significantly higher (0.4-0.6 degrees C) in the group that received water-garment warming when compared with the group that received upper body forced-air warming. The calculated 95% confidence intervals for the above differences in core temperatures were 0.7-0.1, 0.8-0.2, 0.8-0.2, and 0.9-0.1, retrospectively. In addition, 14 and 7% of patients in the control upper body forced-air group remained hypothermic (< 35.5 degrees C) 1 and 2 h after surgery, respectively. No core temperature less than 35.5 degrees C was observed perioperatively in any of the patients from the water-garment group. A similar frequency of the thermal stress events (shivering, use of additional warming devices, subjective thermal discomfort) was observed after extubation in both groups during the 2 h after surgery. CONCLUSIONS: The investigated water warming system, by virtue of its ability to deliver heat to a greater percentage of the body, results in better maintenance of intraoperative normothermia that does forced-air warming applied only to the upper extremities, as is common practice.
Abdomen↗
Double-masked randomized trial comparing alternate combinations of intraoperative anesthesia and postoperative analgesia in abdominal aortic surgery.
BACKGROUND: Improvement in patient outcome and reduced use of medical resources may result from using epidural anesthesia and analgesia as compared with general anesthesia and intravenous opioids, although the relative importance of intraoperative versus postoperative technique has not been studied. This prospective, double-masked, randomized clinical trial was designed to compare alternate combinations of intraoperative anesthesia and postoperative analgesia with respect to postoperative outcomes in patients undergoing surgery of the abdominal aorta. METHODS: One hundred sixty-eight patients undergoing surgery of the abdominal aorta were randomly assigned to receive either thoracic epidural anesthesia combined with a light general anesthesia or general anesthesia alone intraoperatively and either intravenous or epidural patient-controlled analgesia postoperatively (four treatment groups). Patient-controlled analgesia was continued for at least 72 h. Protocols were used to standardize perioperative medical management and to preserve masking intraoperatively and postoperatively. A uniform surveillance strategy was used for the identification of prospectively defined postoperative complications. Outcome evaluation included postoperative hospital length of stay, direct medical costs, selected postoperative morbidities, and postoperative recovery milestones. RESULTS: Length of stay and direct medical costs for patients surviving to discharge were similar among the four treatment groups. Postoperative outcomes were similar among the four treatment groups with respect to death, myocardial infarction, myocardial ischemia, reoperation, pneumonia, and renal failure. Epidural patient-controlled analgesia was associated with a significantly shorter time to extubation (P = 0.002). Times to intensive care unit discharge, ward admission, first bowel sounds, first flatus, tolerating clear liquids, tolerating regular diet, and independent ambulation were similar among the four treatment groups. Postoperative pain scores were also similar among the four treatment groups. CONCLUSIONS: In patients undergoing surgery of the abdominal aorta, thoracic epidural anesthesia combined with a light general anesthesia and followed by either intravenous or epidural patient-controlled analgesia, offers no major advantage or disadvantage when compared with general anesthesia alone followed by either intravenous or epidural patient-controlled analgesia.
Aged↗
Training perioperative physicians.
It has been widely suggested that the specialty of anesthesiology should alter its traditional focus on the technical aspects of intraoperative care toward an expansion of its responsibilities and promotion of the profession as the practice of perioperative medicine. At Vanderbilt University School of Medicine, a program and a practice of perioperative medicine is being developed that reflects the expectation that such activity constitutes appropriate evolution of the profession, improves patient care, improves specialty image, and increases the ability to attract high-quality house-staff.
Anesthesiology↗
A proposed method for the measurement of anesthetist care variability.
OBJECTIVE: Some critical events in anesthesiology occur as seemingly preventable misadventures, their exact origins indeterminable. Inexperienced anesthetists, anesthesia machine malfunctions, lack of vigilance and human error inevitably initiate some incidents. Anesthesia training improves recognition and decision-making. Avoiding crisis initiation and amelioration of those that do occur is one role of the consultant anesthesiologist. Safe patient care requires medical and procedural knowledge, technical expertise, and control of resources in a complex milieu. Anesthesia simulators are clinical laboratories where anesthetists can sharpen both cognitive and manual skills. Dynamic scenarios allow opportunities for anesthetists to explore and experience crises as they develop and apply their knowledge while attempting to manage these events. Simulator-based scenarios are reproducible and large amounts of useful data can be collected and saved. The authors hypothesize these data can be utilized to compare performance of anesthetists and to measure improvement of individual anesthetists over time. METHODS: We have designed "Stable Anesthesia," a prototypic scenario to test anesthetists' capabilities under the stress of performance guidelines. Three subjects performed anesthesia using the simulator and this protocol. Data from the simulator were archived by the system and analyzed by the authors. RESULTS: A simple mathematical analysis gave good separation of data from three subjects of different training level. CONCLUSIONS: It is suggested that the use of the techniques mentioned here may be of value in the development of a standardized testing protocol for anesthetists.
Anesthesiology↗
IMpRH server: an RH mapping server available on the Web.
SUMMARY: The INRA-Minnesota Porcine Radiation Hybrid (IMpRH) Server provides both a mapping tool (IMpRH mapping tool) and a database (IMpRH database) of officially submitted results. The mapping tool permits the mapping of a new marker relatively to markers previously mapped on the IMpRH panel. The IMpRH database is the official database for submission of new results and queries. The database not only permits the sharing of public data but also semi-private and private data.
Animals↗
Assessment of cardiovascular risks and overall risks for noncardiac surgery.
Appropriate care of the elderly patient requires a concerted multi-disciplinary approach before, during, and after surgery to optimize functional outcomes, with the principal focus placed on improving quality of life and strategies for risk reduction. Perioperative physicians must be able to assess the biologic, not the chronologic, age of geriatric patients and their capacity for independent function. Physicians need to understand alterations in the physiology of elderly patients attributable to the normal aging process as well as the prevalence of concurrent pathologic conditions that necessitate special precautions. Maintaining autonomy and function as a result of an acute surgical intervention may be the most important outcome to the elderly patient. Most of the data available and guidelines promulgated do not specifically address the elderly population. It is important to collect data prospectively and use sophisticated methods for analyses to develop better management algorithms for these (often complicated) clinical issues in the elderly.
Aged↗
Successful strategies for improving operating room efficiency at academic institutions.
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Academic Medical Centers↗
Declination angle and its role in selecting surgical telescopes.
BACKGROUND: Clinicians usually expect manufacturers to provide properly adjusted surgical telescope products. However, to ensure optimal selection and adjustment, the clinician must understand certain contributing factors, particularly the optical declination angle. METHODS: The authors have developed a simple, stepwise approach for determining a clinician's optimal working posture and declination angle. This information is then applied to each specific surgical telescope to assist the clinician in ascertaining whether the telescopes comply, or can be made to comply, with the individual needs of the clinician. RESULTS: After the optimal working posture and declination angle have been identified and defined, any surgical magnification system can be evaluated for suitability and proper adjustment. CONCLUSIONS: Declination angle is a key feature in the selection and adjustment of surgical telescope systems, permitting telescopes to be adjusted to meet the clinician's needs instead of forcing the clinician to make compromises to fit the telescopes. CLINICAL IMPLICATIONS: Properly selected and well-adjusted surgical telescopes can enhance dental operating postures and positions, resulting in sound clinical ergonomics. Poor selection and adjustment can result in poor postures and positions.
Ergonomics↗
Construction of a whole-genome radiation hybrid panel for high-resolution gene mapping in pigs.
We have developed a panel of 152 whole-genome radiation hybrids by fusing irradiated diploid pig lymphocytes or fibroblasts with recipient hamster permanent cells. The number and size of the porcine chromosome fragments retained in each hybrid clone were checked by fluorescence in situ hybridization with a SINE probe or by primed in situ labeling (PRINS) with SINE-specific primers. A strategy based on the interspersed repetitive sequence polymerase chain reaction (IRS-PCR) was developed for selected clones to determine if the large fragments painted by the SINE probe corresponded to one pig chromosome or to different fragments of several chromosomes. This strategy was buttressed by a double PRINS approach using primers specific for alpha-satellite sequences of two different groups of swine chromosomes. Genome retention frequency was estimated for each clone by PCR with 32 markers localized on different porcine chromosomes. Of the 152 hybrids produced, 126 were selected on the basis of cytogenetic content and chromosome retention frequency to construct a radiation hybrid map of swine chromosome 8. Our initial results for this chromosome indicate that the resolution of the radiation hybrid map is 18 times higher than that obtained by linkage analysis.
Animals↗
Perioperative maintenance of normothermia reduces the incidence of morbid cardiac events. A randomized clinical trial.
OBJECTIVE: To assess the relationship between body temperature and cardiac morbidity during the perioperative period. DESIGN: Randomized controlled trial comparing routine thermal care (hypothermic group) to additional supplemental warming care (normothermic group). SETTING: Operating rooms and surgical intensive care unit at an academic medical center. SUBJECTS: Three hundred patients undergoing abdominal, thoracic, or vascular surgical procedures who either had documented coronary artery disease or were at high risk for coronary disease. OUTCOME MEASURE: The relative risk of a morbid cardiac event (unstable angina/ischemia, cardiac arrest, or myocardial infarction) according to thermal treatment. Cardiac outcomes were assessed in a double-blind fashion. RESULTS: Mean core temperature after surgery was lower in the hypothermic group (35.4+/-0.1 degrees C) than in the normothermic group (36.7+/-0.1 degrees C) (P<.001) and remained lower during the early postoperative period. Perioperative morbid cardiac events occurred less frequently in the normothermic group than in the hypothermic group (1.4% vs 6.3%; P=.02). Hypothermia was an independent predictor of morbid cardiac events by multivariate analysis (relative risk, 2.2; 95% confidence interval, 1.1-4.7; P=.04), indicating a 55% reduction in risk when normothermia was maintained. Postoperative ventricular tachycardia also occurred less frequently in the normothermic group than in the hypothermic group (2.4% vs 7.9%; P=.04). CONCLUSION: In patients with cardiac risk factors who are undergoing noncardiac surgery, the perioperative maintenance of normothermia is associated with a reduced incidence of morbid cardiac events and ventricular tachycardia.
Aged↗
Perioperative ischemia and cardiac complications in major vascular surgery: importance of the preoperative twelve-lead electrocardiogram.
PURPOSE: To investigate the associations between specific preoperative 12-lead electrocardiogram (ECG) abnormalities, perioperative ischemia, and postoperative myocardial infarction or cardiac death in major vascular surgery. METHODS: Two prospective studies on perioperative myocardial ischemia performed in two tertiary university hospitals were combined to include 405 patients. All preoperative ECGs were analyzed according to the Sokolow-Lyon criteria for left ventricular hypertrophy by investigators who were blinded to the patients' perioperative clinical course. Perioperative myocardial ischemia was detected by continuous ECG recording, and postoperative cardiac complications included myocardial infarction and cardiac death. RESULTS: A total of 19 postoperative cardiac complications occurred (two cardiac deaths and 17 myocardial infarctions). Voltage criteria for left ventricular hypertrophy (78 patients, 19%) and ST segment depression greater than 0.5 mm (98 patients, 24.2%) on preoperative ECGs were both significantly associated with postoperative myocardial infarction or cardiac death (odds ratio, 4.2 and 4.7; p = 0.001 and 0.0005, respectively) and with longer intraoperative and postoperative myocardial ischemia. In each of the two study groups, a preoperative ECG abnormality that involved voltage criteria, ST segment depression, or both (134 patients, 33.1%) was more predictive of postoperative cardiac complications than any other preoperative clinical variable, including a history of myocardial infarction or angina pectoris, diabetes mellitus, pathologic Q-wave by ECG, or preoperative myocardial ischemia. The combined duration of intraoperative and postoperative ischemia and the preoperative ECG with either voltage criteria or ST segment depression were the only independent factors associated with adverse cardiac events by multivariate analysis (p < or = 0.0001 and p = 0.02, respectively). CONCLUSION: Left ventricular hypertrophy and ST segment depression on preoperative 12-lead ECGs are important markers of increased risk for myocardial infarction or cardiac death after major vascular surgery.
Aged↗
Changes in cerebrospinal fluid pressure and lactate concentrations during thoracoabdominal aortic aneurysm surgery.
BACKGROUND: Although ischemic injury to the spinal cord is a well-known complication of aortic surgery, no metabolic markers have been identified as predictors of an adverse outcome. This study evaluated the effect of cerebrospinal fluid (CSF) drainage, with and without distal femoral perfusion or moderate hypothermia on blood and CSF lactate concentrations and CSF pressure during thoracoabdominal aortic aneurysm surgery. METHODS: Three nonconcurrent groups of patients were studied prospectively: patients with normal body temperature (35 degrees C) but without distal femoral bypass (n = 6), patients with normal body temperature with bypass (n = 7), and patients with hypothermia (30 degrees C) and bypass (n = 8). In all patients, CSF pressure was recorded before, during, and after aortic cross-clamping. During the surgical repair, CSF drainage was performed using a 4-Fr intrathecal silicone catheter. Blood and CSF lactate concentrations were measured throughout the operation. RESULTS: Significant increases in blood (490%) and CSF (173%) lactate concentrations were observed during and after thoracic aortic occlusion in patients with normothermia and no bypass (P < 0.02 and 0.05, respectively). Distal perfusion attenuated the increase in both blood and CSF lactate (P < 0.01), and a further reduction was achieved with hypothermia of 30 degrees C (P < 0.001). Patients who became paraplegic showed a greater increase in CSF lactate concentrations after aortic clamp release compared with those who suffered no neurological damage (275% vs. 123% of baseline; P < 0.05). Increased CSF pressure of 42-60% (P < 0.005) was noted soon after thoracic aortic occlusion, both with and without distal femoral bypass. CONCLUSIONS: Incremental reductions in CSF lactate concentrations were achieved using distal femoral bypass and hypothermia. The reduction in CSF lactate correlated with the methods used to protect the spinal cord during thoracoabdominal aortic aneurysm surgery and was associated with better outcome. Decompression by distal bypass of the hemodynamic overload caused by aortic occlusion was insufficient to eliminate the acute increase in CSF pressure. Cerebrospinal fluid lactate measurements during high aortic surgery may accurately represent the spinal cord metabolic balance.
Adult↗
Potent in vivo inhibitors of rat renin: analogues of human and rat angiotensinogen sequences containing different classes of pseudodipeptides at the scissile site.
Using solid-phase methodology we have synthesised peptides based on the 8-14 or 6-14 human and rat angiotensinogen sequences, containing the following different isosteric units at the P1-P1' cleavage site: Leu-psi[CH2NH]Leu; Leu-psi[CH(OH)CH2]Val; Leu-psi[CH(OH)CH2]Leu and Leu-psi[CH(NH2)CH2]Val. In vitro, peptide Piv-His-Pro-Phe-His-Leu-psi[CH(OH)CH2]Leu-Tyr-Tyr-Ser-NH2(XXI) is the most potent inhibitor of rat plasma renin reported having an IC50 of 0.21 nM; it is a much weaker inhibitor of human renin (IC50 45 nM). Peptide Boc-His-Pro-Phe-His-Leu-psi[CH(OH)CH2] Leu-Val-Ile-His-NH2 (XX) was a highly effective inhibitor of rat renin in vivo. When infused (1 mg/kg/h) into two-kidney, one-clip chronic renal hypertensive rats, it lowered blood pressure and suppressed both plasma renin and angiotensin II. When given as a bolus (1 mg/kg) there was a divergence between the rapid rebound of renin levels and blood pressure, which remained suppressed. These results indicate that potent in vivo inhibitors of rat renin could be useful not only in examining the role of circulating renin but also in elucidating the equally important involvement of extracirculatory renin pools.
Amino Acids↗
Anaesthesia for major vascular surgery.
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Anesthesia, General↗
Control of blood pressure and heart rate in patients randomized to epidural or general anesthesia for lower extremity vascular surgery. Perioperative Ischemia Randomized Anesthesia Trial (PIRAT) Study Group.
STUDY OBJECTIVE: To examine the degree of success at maintaining patients randomized to epidural or general anesthesia for peripheral vascular surgery within predetermined blood pressure (BP) and heart rate (HR) limits. To investigate associations between such hemodynamic control and intraoperative myocardial ischemia and postoperative major cardiac morbidity. DESIGN: Prospective randomized clinical trial. SETTING: University-affiliated hospital. PATIENTS: 100 patients undergoing elective lower extremity revascularization for atherosclerotic peripheral vascular disease. INTERVENTIONS: Patients were randomized to receive either epidural anesthesia or general anesthesia. Blood pressure and HR limits were determined prior to randomization. Hemodynamic monitoring and management of anesthesia was standardized. Myocardial ischemia and major cardiac morbidity were diagnosed by a blinded cardiologist, based on continuous ambulatory ECG monitoring, cardiac enzymes, and 12 lead ECGs. Intraoperative BP and HR date were analyzed by investigators masked to the type of anesthesia given. MEASUREMENTS AND MAIN RESULTS: A greater percentage of patients randomized to general anesthesia had intraoperative BPs more above their limit (95% vs 72%, p = 0.002) and/or more rapid changes in HR (75% vs 48%, p = 0.008) or BP (100% vs 93%, p = 0.04) than those randomized to epidural anesthesia. Intraoperative ischemia and major cardiac morbidity were similar in the two anesthesia groups. Patients experiencing intraoperative ischemia, regardless of anesthetic type, more frequently had BPs greater than 10% above their upper limit (90% vs 60% p = 0.04) and/or more rapid HR changes (90% vs 58%, p = 0.03) compared with patients without ischemia. These vital sign abnormalities, however, were not necessarily temporally related to the ischemic episodes. Patients experiencing subsequent major cardiac morbidity were not different from other patients with respect to excursions out of BP on HR limits. CONCLUSIONS: Prevention of elevated intraoperative BP and/on rapid changes in BP or HR may be more successful with epidural than with general anesthesia. Such vital sign abnormalities may occur more frequently in patients who have had intraoperative ischemia or are at risk for having it later in the procedure.
Aged↗