Density of spinal anaesthetic solutions.
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Anesthesia, Spinal↗
Biomedical subjects
M Pitkänen
Publications and source records attributed to M Pitkänen.
The connection between age, job control and sickness absences among Finnish food workers.
METHODS: The relationship between sickness absence and job control among industrial food workers of different ages (n = 114) was studied. RESULTS: The number of absence spells, particularly short absence spells, was higher among younger workers, as expected. Using multivariate analysis, low job control was associated with an increased number of all absence spells (P < 0.02). CONCLUSIONS: Job control may be an important factor in determining sickness absence among industrial workers.
Absenteeism↗
Patient-controlled epidural analgesia versus continuous epidural analgesia after total knee arthroplasty.
BACKGROUND: Patient-controlled epidural analgesia (PCEA) has been found to be an effective method for pain relief during labour and after surgery. The goal of this study was to compare the efficacy of bupivacaine-fentanyl PCEA and continuous epidural infusion with the same mixture for treatment of pain after total knee arthroplasty. METHODS: Fifty-four patients under spinal anaesthesia were allocated to two groups in this randomized, double-blind study: the PCEA group could demand a bolus of 0.05 ml/kg of the bupivacaine 1.1 mg/ml and fentanyl 5 microg/ml solution, with a lockout interval of 10 min and total dose limit of three bolus doses per hour. The EPI group received a continuous infusion of 0.1 ml kg(-1) h(-1) of the same bupivacaine-fentanyl solution, and only a minimal extra bolus dose of 0.2 ml with the same lockout interval. All the patients received also paracetamol 1 g, orally, three times a day. In addition to pain scores at rest and during leg lifting, the 20-h analgesic consumption and the incidence of side effects were recorded. RESULTS: Forty-nine patients completed the study. The bupivacaine and fentanyl consumption during 20 h was smaller in the PCEA group (P<0.001). Analgesia and the need for rescue-opioid medication were similar in both groups. There were no differences between the PCEA and EPI groups regarding the incidence of side effects. Five patients were confused about how to operate the PCEA apparatus. CONCLUSION: The amount of bupivacaine-fentanyl solution consumed was significantly less with PCEA than with continuous infusion of bupivacaine-fentanyl solution without affecting the quality of postoperative analgesia after total knee arthroplasty. Several of the elderly patients had difficulties in operating the PCEA apparatus.
Acetaminophen↗
Continuous epidural analgesia with bupivacaine-fentanyl versus patient-controlled analgesia with i.v. morphine for postoperative pain relief after knee ligament surgery.
BACKGROUND: Both epidural analgesia and intravenous patient-controlled analgesia (PCA) have been found efficacious after various types of surgery. We compared the efficacy, safety, side effects and patient satisfaction of these methods in a randomized double-blind fashion after elective anterior cruciate ligament reconstruction of the knee. METHODS: Fifty-six patients had an epidural catheter placed at the L2-L3 interspace. Spinal anaesthesia with 15 mg of plain bupivacaine 5 mg/ml was performed at the L3-L4 interspace. After surgery the patients were randomly divided into three groups: 19 received a continuous epidural infusion with bupivacaine 1 mg/ml and fentanyl 10 mg/ml (F10), 19 patients received bupivacaine 1 mg/ml and fentanyl 5 microg/ml (F5) and 18 patients received saline (S). The rate of the epidural infusions was 0.1 ml kg(-1) h(-1). Each patient could also use an intravenous (i.v.) PCA device with 40 microg/kg bolus doses of morphine with a lockout period of 10 min and a maximum dose 240 microg kg(-1) h(-1). At the end of surgery ketoprofen 100 mg i.v. was given and continued orally three times a day. Patients were assessed for pain with a visual analogue scale (VAS) at rest and during activity, side effects and satisfaction at 3, 9 and 20 h. RESULTS: Both epidural infusions (F10, F5) provided better analgesia than epidural saline plus i.v. PCA (S) (P<0.05). There was slightly less nausea in the S group (NS). In spite of the difference in the quality of pain relief, there was no difference between the groups in patient satisfaction regarding analgesic therapy. CONCLUSION: Epidural infusion of fentanyl (1 microg kg(-1) h(-1) or 0.5 microg kg(-1) h(-1)) and bupivacaine (0.1 mg kg(-1) h(-1)) provided better pain relief but more side effects than intravenous morphine patient-controlled analgesia after knee ligament surgery. Almost all patients in all groups were satisfied with their pain relief.
Adolescent↗
Comparison of hypotensive epidural anaesthesia and spinal anaesthesia on blood loss and coagulation during and after total hip arthroplasty.
BACKGROUND: Hypotensive epidural anaesthesia (HEA) is a technique for reducing peroperative blood loss by significantly lowering mean arterial pressure (MAP). METHODS: Thirty patients scheduled for primary total hip arthroplasty were given HEA (n=15) or spinal anaesthesia (SPA) (n= 15) with bupivacaine in random order. The dose of bupivacaine was titrated to provide epidural blockade up to T1-T4 and spinal blockade at least to T10. Intravenous adrenaline infusion was adjusted to achieve a MAP of about 50-60 mmHg in the HEA group. During SPA MAP was maintained above 70 mmHg with ephedrine, as needed. RESULTS: Intraoperative blood loss (median and 25th and 75th percentiles) was 400 ml (163-575) in the HEA group and 900 ml (663-1,100) in the SPA group (P<0.05). At 3 h postoperatively cumulative blood loss was still smaller in the HEA group (600 ml versus 1,100 ml, P<0.05). The cumulative number of transfused packed red cell concentrate (PRC) units was smaller in the HEA group than in the SPA group during surgery and postoperatively. Prothrombin time value was smaller in the SPA than in the HEA group (69% versus 79%, P<0.05) at 3 h postoperatively. D-dimer concentrations increased more in the SPA group at the end of the surgery and 3 h postoperatively (P<0.05). CONCLUSIONS: HEA resulted in reduced blood loss due to hypotension and reduced number of transfused PRC units during total hip arthroplasty. Based on lower prothrombin time value and higher D-dimer concentrations in the SPA group, the coagulation system might be better preserved during HEA than SPA.
Aged↗
Comparison of intravenous patient-controlled analgesia with tramadol versus morphine after microvascular breast reconstruction.
Tramadol is a weak centrally acting analgesic and it might provide efficacious postoperative pain relief with minimal sedative effects in the use of intravenous patient-controlled analgesia (PCA). Sixty women scheduled to undergo microvascular breast reconstruction under standard general anaesthesia were enrolled in a study on the performance of patient-controlled analgesia with tramadol or morphine with special emphasis on drug- and technique-related side-effects. Seven patients were re-operated within the same day, leaving 25 patients in the tramadol group and 28 in the morphine group for comparison. When postoperative pain occurred, loading doses of either 10 mg tramadol or 1 mg morphine intravenous increments were administered in a double-blind fashion until the pain control was judged to be satisfactory by the patient. After that the patients received tramadol or morphine by a PCA apparatus (lockout 5 min, tramadol 450 microg kg-1, morphine 45 microg kg-1 bolus). In addition, all patients received 500 mg paracetamol rectally, three times a day. The potency ratio of tramadol to morphine was found to be between 8.5 : 1 (loading) and 11 : 1 (PCA). There was neither a significant difference between the groups in the overall satisfaction of the analgesic medication nor in the visual analogue and verbal rate scales for pain. Women in the tramadol group had more nausea and vomiting during the administration of loading doses (P < 0.05) and more patients in the tramadol group (7) than in the morphine group (3) (NS) wanted to discontinue the PCA therapy before the end of the study due to nausea. Sedation or blurred vision prevented the performance of the psychomotor tests in 22 and 32% of the tramadol and morphine patients, respectively. The remaining patients performed similarly in the Digit Symbol Substitution Test. In women receiving intravenous PCA for analgesia after microvascular breast reconstruction tramadol and morphine provided comparable postoperative analgesia with similar sedative effects. However, tramadol was associated with a disturbingly high incidence of nausea and vomiting.
Acetaminophen↗
Computed tomography findings 4 years after surgical management of lumbar spinal stenosis. No correlation with clinical outcome.
STUDY DESIGN: A prospective, cross-sectional study of the correlation between postoperative computed tomography findings and patients' clinical outcomes approximately 4 years after laminectomy for lumbar spinal stenosis. OBJECTIVES: To evaluate clinical and radiologic characteristics and their relation to each other. SUMMARY OF BACKGROUND DATA: The goal of surgical management for lumbar spinal stenosis is to decompress the stenotic area determined in radiologic examinations to relieve pressure on the neurovascular structures. However, the success of this decompression very rarely has been confirmed by postoperative radiologic imaging or compared with clinical outcome. METHODS: Postoperative computed tomography was performed on 191 patients. The findings were classified as "no stenosis," "central stenosis," "lateral stenosis," or "central-lateral stenosis." Postoperative instability of the lumbar spine was investigated by functional radiography. Clinical status was assessed by clinical examination. Subjective disability was assessing using the Oswestry questionnaire, and severity of pain using the visual analog scale. Walking capacity was evaluated by the tread-mill test. RESULTS: Radiologic studies revealed postoperative stenosis in 123 patients (64%). Small differences between the computed tomography groups were shown for the Oswestry score, but not for walking distance. Clinical signs, severity of pain, and radiologic instability were very similar for all computed tomography groups. CONCLUSIONS: Postoperative radiologic stenosis was very common in patients operated on for lumbar spinal stenosis, but this did not correlate with clinical outcome. The clinician must be cautious when reconciling clinical symptoms and signs with postoperative computed tomography findings in patients operated on for lumbar spinal stenosis.
Disability Evaluation↗
Quality control in health care: an experiment in radiotherapy planning for breast cancer patients after mastectomy.
PURPOSE: The importance of evaluating and improving quality in clinical practice is now generally acknowledged. In this study we estimated different sources of variation in radiotherapy planning for breast cancer patients after mastectomy and sought to test the applicability of a reproducibility and repeatability (R&R) study in a clinical context. METHODS: Eleven radiation oncologists planned radiotherapy three times for three different kinds of breast cancer patients without knowing they were handling the same patient three times. Variation was divided into different components: physicians as operators, patients as parts, and repeated measurements as trials. Variation due to difference across trials (repeatability), that across the physicians (reproducibility), and that across the patients (variability) were estimated, as well as interactions between physicians and patients. Calculation was based on the sum of squares, and analysis was supported by various graphical presentations such as range charts and box plots. RESULTS: Some parts of the planning process were characterized by higher and different kinds of variation than the others. Interphysician variation (i.e., reproducibility) was not high but there were some clearly outlying physicians. The highest variation was in repeatability (= intraphysician variation). The major part of the variation was, however, that from patient to patient: 33% of the total in Parameter 1 and 85% of the total in Parameter 2. CONCLUSIONS: R&R studies are applicable and are needed to evaluate and improve quality in clinical practice. This kind of analysis provides opportunities to establish which kinds of patients require particularly careful attention, which points in the process are most critical for variation, which are the most difficult aspects for each physician and call for more careful description in documents, and which physicians need further training.
Analysis of Variance↗
Nitric oxide synthesis inhibition modifies the cardiotoxicity of tetracaine and lidocaine.
UNLABELLED: Suppression of nitric oxide (NO) production alters the toxicity of cocaine and bupivacaine. We undertook this study to determine whether the systemic toxicity of two other local anesthetics that differ in antiarrhythmic activity, plasma clearance, and biotransformation are similarly affected by nitric oxide synthase (NOS) inhibition. Sprague-Dawley rats anesthetized with 70% N2O and 0.5% halothane mixed with O2 were pretreated with saline (0.2 mL x kg(-1) x min(-1) i.v.) or N(omega)-nitro-L-arginine methyl ester (L-NAME; a competitive inhibitor of NOS) (2 mg x kg(-1) x min(-1) i.v.) for 30 min. The animals were then given tetracaine (3 mg x kg(-1) x min(-1) i.v.) or lidocaine (8 mg x kg(-1) x min(-1) i.v.) until cardiac arrest (asystole). Doses of lidocaine or tetracaine that produced arrhythmias, seizures, isoelectric encephalogram, and asystole were determined. Hemodynamic recordings were performed throughout the experiments, and plasma was collected to measure the concentration of lidocaine or tetracaine. L-NAME decreased tetracaine and lidocaine doses that produced arrhythmias (> or = 2 degrees atrioventricular conduction block) (tetracaine 14 +/- 2 mg/kg; lidocaine 102 +/- 9 mg/kg) versus saline treatment (tetracaine 28 +/- 2 mg/kg; lidocaine 136 +/- 9 mg/kg; P < 0.05). The tetracaine and lidocaine doses required to produce asystole were also smaller in animals with L-NAME pretreatment than those in saline-pretreated animals. L-NAME reduced the arrhythmia dose of tetracaine more than the arrhythmia dose of lidocaine (28 of 14 = 2.0 fold and 136 of 102 = 1.3-fold). The plasma concentration of lidocaine, but not tetracaine, was significantly higher at each sample time in L-NAME-pretreated animals than in saline-pretreated animals. Inhibition of NOS by L-NAME enhances the cardiotoxicity of lidocaine and tetracaine, with a greater effect on tetracaine than on lidocaine. Altered drug clearance by L-NAME was insufficient to explain these findings because L-NAME pretreatment increased the plasma levels of only lidocaine, not tetracaine. IMPLICATIONS: Inhibition of nitric oxide production in rats markedly enhances the cardiovascular toxicity of lidocaine and tetracaine. Altered drug clearance by N(omega)-nitro-L-arginine methyl ester was insufficient to explain these findings because N(omega)-nitro-L-arginine methyl ester pretreatment increased the plasma levels of only lidocaine, not tetracaine.
Anesthetics, Local↗
Regional anaesthesia for low back operations.
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Anesthesia, General↗
Comparison of analgesic efficacy of oxycodone and morphine in postoperative intravenous patient-controlled analgesia.
BACKGROUND: Morphine has been the standard opioid in patient-controlled analgesia (PCA). Oxycodone, the analgesic potency of which in i.v. administration has been suggested to be slightly greater than that of morphine, has not yet been studied for its efficacy in PCA. METHODS: Fifty patients, undergoing a plastic reconstruction of the breast or a major operation of the vertebrae, such as lumbar spinal fusion, used PCA for postoperative pain. Patients were randomized to receive either morphine 45 microg/kg or oxycodone 30 microg/kg as i.v. bolus doses. Patients were assessed for pain with a visual analogue scale (VAS) and side effects at 3, 9 and 24 h. Venous blood samples for the measurement of plasma concentration of oxycodone and that of morphine and its metabolites were taken. RESULTS: In this study patients needed, on average, the same amount of oxycodone and morphine in the recovery room and on the ward. There was no difference in the quality of analgesia (VAS) or incidence of side effects, such as nausea, vomiting, pruritus and urinary retention. The plasma concentrations of morphine-6-glucuronide showed that this metabolite might contribute to the analgesia resulting from morphine administration. CONCLUSIONS: The same dose of intravenous oxycodone and morphine administered by PCA pump was needed for immediate postoperative analgesia. The two drugs appear to be equipotent.
Adult↗
Limited usefulness of traction-compression films in the radiographic diagnosis of lumbar spinal instability. Comparison with flexion-extension films.
STUDY DESIGN: A prospective, within-patient comparison of two methods for functional radiography of lumbar spine with consecutive patients. OBJECTIVE: To evaluate the usefulness of traction-compression radiography compared with conventional flexion-extension radiography in diagnosis of lumbar spinal instability. SUMMARY OF BACKGROUND DATA: Flexion-extension radiography generally is used and widely recognized as an effective method for diagnosis of segmental lumbar spinal instability, but the usefulness and findings of traction-compression films are less well known. METHODS: Flexion-extension and traction-compression radiography were performed on 306 consecutive patients (mean age, 43 years; range, 14-68 years) with clinically suspected lumbar spinal instability. Radiography was performed of each patient in an upright position. Axial traction was accomplished by letting the patient hang by his or her hands from a horizontal bar. Compression views were taken when the patient had sandbags of approximately 30% of the his or her weight on the shoulders. Main interest was translational forward and backward displacement of one vertebra on another. RESULTS: Signs of translational instability were present on the functional radiographs of 27% (84 of 306) of the patients. In diagnosis of instability, the overall agreement of flexion-extension and traction-compression films was only 0.786, and also statistic Kappa remained poor (0.05). Flexion-extension films more frequently revealed signs of instability than traction-compression films: 81 versus seven patients. CONCLUSIONS: Traction-compression films seem to be of questionable value in diagnosis of lumbar spinal instability.
Adolescent↗
Image processing for femoral endosteal anatomy detection: description and testing of a computed tomography based program.
A computed tomography (CT)-based image processing computer program was developed for three-dimensional (3D) femoral endosteal cavity shape modelling. For the examinations 50 cadaver femora were used. In the CT imaging 30 axial slices were taken above and below the lesser trochanter area from each femur. Different image analysis methods were used for femoral cavity detection depending on the structure of the processed slice. In the femoral shaft area simple thresholding methods succeeded, but in the problem areas of the metaphyseal femur edge, detection operators and local thresholding were required. In contour tracking several criteria were used to check the validity of the border pixels. The results were saved as four output data files: (i) a file for the longest anteroposterior (ap), mediolateral (ml) and oblique diameters computed by a Euclidian method, (ii) and (iii) files for 2D and 3D data respectively, and (iv) a file for centre points of each slice. Finally, testing of the results and dimensions obtained from the image analysis were carried out manually by sawing the femora into 10 stipulated horizontal slices. The ap and ml dimensions were measured with a caliper ruler. The CT-based image processing yielded a peak distribution of dimensions with a negative difference to those obtained in manual measurements. The mean difference between the image processing and the manual measurements was 1.1 mm (+/-0.7 mm, +/-1 SD). The difference was highest in the proximal slices of the femora of group I (with lowest cortical thickness), i.e. 1.3 mm (+/-0.8 mm) and lowest in the distal slices of the femora from group III (with highest cortical thickness), i.e. 0.9 mm (+/-0.6 mm). The results are acceptable for further use of the program to study endosteal anatomy for individual femoral component selection and designing basis.
Cadaver↗
Intrathecal infusion of bupivacaine with or without morphine for postoperative analgesia after hip and knee arthroplasty.
Postoperative pain after major orthopaedic operations can be controlled by continuous intrathecal administration of opioids or local anaesthetics. Effective intrathecal analgesia can be achieved through synergism of low doses of the two analgesic drugs and, possibly, less drug-related adverse effects. Therefore, we have evaluated the usefulness of a combined low-dose bupivacaine and morphine infusion in patients undergoing hip and knee arthroplasty. Spinal anaesthesia was induced in 55 ASA I-III patients with 0.5% bupivacaine 2 ml via a 28-gauge spinal catheter (L3-4 interspace) and 0.5-ml increments were given if needed. Intrathecal 24-h infusions consisted of bupivacaine 2 mg h-1 alone (n = 18), bupivacaine 1 mg h-1 alone (n = 18) or bupivacaine 1 mg h-1 combined with morphine 8 micrograms h-1 (n = 19). The interview after 3, 6, 12 and 24 h included assessment of pain at rest and on movement (VAS scale), occurrence of sensory and motor block and nausea/vomiting. Bupivacaine 1 mg h-1 combined with an infusion of morphine provided as good postoperative analgesia as bupivacaine 2 mg h-1, but motor block disappeared earlier (P = 0.01). Patients in the bupivacaine 1-mg h-1 group required more supplementary doses of oxycodone i.m. than the other groups (P = 0.04). Time to first oxycodone dose from the start of intrathecal infusion did not differ between groups. The frequency of nausea and vomiting was similar in all groups. In spite of this, antiemetic medication was required more often in the bupivacaine 1-mg h-1 group (possible because of opioid rescue medication). On the ward, one patient in the bupivacaine 2-mg h-1 group experienced a new increase in sensory block with concomitant hypotension. One patient in the same group had minor decubitus on the heel of the operated leg, probably because of prolonged motor block. We conclude that intrathecal infusion of a combination of bupivacaine 1 mg h-1 and morphine 8 micrograms h-1 produced adequate postoperative analgesia. Unfortunately, postoperative nausea and vomiting was a frequent disturbing adverse effect.
Adult↗
Knee-chest vs horizontal side position during induction of spinal anaesthesia in patients undergoing lumbar disc surgery.
In the prone knee-chest position the spread of plain 0.5% bupivacaine in the cerebrospinal fluid and associated haemodynamic changes may be different compared with the horizontal position. A randomized comparison was performed in 40 ASA I-II patients, aged 24-61 yr, undergoing lumbar disc surgery. Subarachnoid injection (27-gauge needle) at the L2-3 interspace with 3 ml of 0.5% bupivacaine was performed with the patient in the operative knee-chest position (prone knee-chest group, n = 20) or in the horizontal side position (supine side horizontal group, n = 20). Patients in the supine side horizontal group were turned into the horizontal supine position for 20 min, and subsequently they were placed in the operative knee-chest position. In three patients in the prone knee-chest group, the spinal needle was replaced by a larger needle (25-gauge). The final cephalad extension of sensory analgesia on skin tested by pinprick was T5 (median) in the prone knee-chest group and T6 in the supine side horizontal group. Recovery was also similar, on average 210 min from injection in both groups. The mean decrease in systolic arterial pressure was somewhat greater in the prone knee-chest group (30 mm Hg) than in the supine side horizontal group (13 mm Hg). The need for ephedrine occurred earlier in the supine side horizontal group (three patients, all within 10 min from local anaesthetic injection) than in the prone knee-chest group (six patients, all after 15 min). Four of the latter patients also required administration of an anticholinergic for bradycardia compared with two patients in the supine side horizontal group. Light sedation was given to five patients in the prone knee-chest group and to four in the supine side horizontal group because of numbness and aching in the shoulders. We conclude that spinal block was similar in the two groups but there was a tendency to more frequent episodes of haemodynamic deterioration in the knee-chest position.
Adult↗
Accuracy of dose delivery in gynecological brachytherapy.
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Brachytherapy↗
Evaluation of the usefulness of intrathecal bupivacaine infusion for analgesia after hip and knee arthroplasty.
Spinal anaesthesia in 47 ASA I-III patients was induced with 0.5% bupivacaine 2 ml via a 28-gauge spinal catheter (L3-4 interspace) and 0.5-ml increments were given if needed before or during hip or knee arthroplasty. Intrathecal 24-h infusions consisted of 0.5% bupivacaine 0.4 ml h-1 (2 mg h-1) (n = 12), 0.5% bupivacaine 0.2 ml h-1 (1 mg h-1) (n = 12) or saline (n = 11) (12 exclusions). Patients received oxycodone 0.1-0.14 mg kg-1 i.m. for rescue analgesia. Infusion of bupivacaine 2 mg h-1 provided significantly better postoperative analgesia (19 oxycodone doses per group in 24 h) compared with bupivacaine 1 mg h-1 (36 doses of oxycodone per group) and saline (52 doses per group) (P < 0.05). Five patients in the bupivacaine 2-mg h-1 group and none in the other groups had measurable sensory block 24 h after the infusion was started. Three patients in the bupivacaine 2-mg h-1 group, two with concomitant arterial hypotension, and one patient in the bupivacaine 1-mg h-1 group experienced an increase in block on the ward. The incidence of nausea and vomiting was similar in all groups. Although an effective analgesic, intrathecal infusion of bupivacaine 2 mg h-1 cannot be recommended for routine pain relief because of the risk of increasing spinal block. Technical problems (19%) also reduced the overall efficacy of the continuous intrathecal analgesic regimen.
Analgesia↗
Low- and standard-dose depot haloperidol combined with targeted oral neuroleptics.
Nine patients receiving a low dose (25 mg) and ten receiving a standard dose (150 mg) of depot haloperidol every four weeks were assessed every three months for two years. Patients also received targeted oral neuroleptics as needed. No significant between-group differences were found in clinical outcome as measured by number of hospital admissions, days hospitalized, scores on the Brief Psychiatric Rating Scale and the Global Assessment Scale, and level of extrapyramidal symptoms. Combining low-dose depot and targeted oral neuroleptics was at least as effective as using a standard depot dose and for many patients may provide the best way to reach the minimal effective dose for maintenance treatment.
Administration, Oral↗