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PubMed2002

Hospital practice more than specialty influences the choice of regional or general anesthesia for Cesarean section.

PURPOSE: Describe the influence of specialty certification and practice style upon the anesthetic technique used for Cesarean deliveries. METHODS: Alberta physician claims and hospital abstracts between April 1, 1998 to March 31, 2000 were used to determine the technique of anesthesia (regional or general). The influence of practice (volume of deliveries, geographic location, presence of regional analgesia providers) and specialty (anesthesiologist or family/general practice) is explored by logistic regression. RESULTS: Hospital abstracts of 13,884 Cesarean sections were analyzed. Anesthesiologists performed 76% of the anesthetics: epidural (33%), spinal (45%), and general anesthesia (22%). Comparing only regional and metropolitan hospitals, the percent of general anesthesia performed by anesthesiologists varied between 5% to 50%. After adjusting for other factors, we found, in order of importance, the following determined the use of general anesthesia for Cesarean sections: 1) hospitals with more epidural procedure providers during labour were 3% less likely to have providers choose general anesthesia; 2) larger, regional and metropolitan hospitals were less likely to have providers choose general anesthesia; 3) hospitals with a high volume epidural procedure provider during labour were 64% less likely to have providers choose general anesthesia; 4) anesthesiologists were 32% less likely to choose general anesthesia. CONCLUSION: The overall use of regional anesthesia for Cesarean sections in Alberta is high. The chance of receiving a general anesthetic for a Cesarean delivery varies across the province and was more related to practice environment than specialty.

Adult↗
PubMed1994

[No better vigilance after general anesthesia with propofol in colonic surgery. A comparison of three procedures for general anesthesia (propofol, halothane and midazolam/fentanyl) in combination with catheter epidural anesthesia].

Early mental and psychomotor recovery was studied in 67 patients undergoing colorectal surgery under continuous epidural anaesthesia and light general anaesthesia using propofol, halothane, and midazolam/fentanyl. The study was approved by the local ethics committee. All patients received epidural anaesthesia with 0.25% bupivacaine and were then randomly allocated to one of three groups. In group I (halothane), light general anaesthesia was induced with thiopental 3-5 mg/kg and maintained with halothane. The propofol group (II) received 2 mg/kg for induction and a mean continuous infusion of 1.7 mg/kg.h. In group III (Mi/Fe), midazolam and fentanyl were used for induction and maintenance. All patients were intubated, received non-depolarising muscle relaxants, and were manually ventilated with nitrous oxide-oxygen (2:1.2). For postoperative analgesia, 0.05 mg/kg morphine was administrated epidurally 30 min before the end of the operation; 30, 60, 90, and 120 min after arriving in the recovery room, vigilance was assessed using a modified Steward score, the Trieger test, the ability to recall a column of numbers (KAI test), and symbol counting (CI test). Heart rate, blood pressure, arterial oxygen saturation, and blood gases were recorded. RESULTS. The three groups were comparable with regard to age, sex, ASA classification, and duration of anaesthesia and operation (Table 3). There was no difference between the groups in performance of the recovery tests (Figs. 2-5), blood pressure, heart rate, arterial blood gas analysis (Fig. 6), or oxygen saturation. Comparing pre- and postoperative values, we found severe psychomotor and mental impairment in all groups. pCO2 was slightly elevated in all groups, but only 3 patients in the propofol group and 6 in the midazolam/fentanyl group developed hypercapnia above 50 mm Hg. Patients receiving propofol or midazolam/fentanyl had significantly less postoperative nausea and vomiting than those receiving halothane (Table 5). CONCLUSION. It is concluded that propofol offers no advantage over halothane or midazolam/fentanyl where early postoperative recovery is concerned. Intraoperatively, all three techniques provided good anaesthesia. Propofol and midazolam/fentanyl caused less postoperative nausea and vomiting than halothane anaesthesia.

Adult↗
PubMed1995

Combined spinal-epidural-general anesthesia.

Each one of the three kinds of anesthesia (spinal, epidural, general) has its advantages and disadvantages. A new concept of combined spinal-epidural-general anesthesia (CSEGA) is illustrated with the objective of producing a new kind of anesthesia. The aim is to draw out the good from each compartment. CSEGA can be based on muscle relaxation and anesthesia on its spinal part with the epidural augmentation. The endotracheal intubation can be kept in place with a very small dose of an inhalational anesthetic. There is no need for muscle relaxant drugs, i.v. opioids or benzodiazepines, for postoperative analgesia serves the epidural catheter. Very small doses of local anesthetic drugs injected into the spinal or epidural compartments, could be all that is needed for operations on any part of the body, including thorax and head. CSEGA is a new concept in anesthesia. The mixing of regional anesthesia with general anesthesia affords the anesthesiologist the opportunity to lower the local anesthetic doses, avoid using many kinds of intravenous drugs (muscle relaxants, opioids, benzodiazepines, etc.) and to approach a kind of anesthesia that is closer to the ideal.

Anesthesia↗
PubMed1953

General anesthesia in ophthalmology.

General or a combination of local and general anesthesia is beneficial in ophthalmic operations. With foreknowledge that they are to be asleep, patients approach operation with less trepidation, and during the procedure the surgeon can be more relaxed. In a series of 300 cases reviewed, no complications that could be attributed to general anesthesia occurred at the operative site. Nasopharyngeal and tracheal irritation sometimes developed. Anesthesia should be conducted by a well-trained, alert anesthetist; and the method and the agent should be determined after thorough examination and appraisal of the patient and consideration of the nature of the operation to be done.

Anesthesia↗
PubMed1985

General anesthesia.

The general anesthetic course has been made acceptably safe with the development of modern anesthetic agents and techniques and increased capabilities for monitoring patient organ systems. Each area of surgery has features unique to its specialty. Consideration of these aspects when planning an anesthetic and surgical course, as well as the importance of the team effort, cannot be overemphasized.

Anesthesia, General↗
PubMed2004

A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with desflurane for outpatient knee arthroscopy.

In this randomized and controlled trial, 64 adult ambulatory knee arthroscopy patients received either selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane. We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities, a shorter stay in the postanesthesia care unit, and earlier discharge home compared with GA with desflurane. Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group. No difference was seen in the fast-tracking possibilities or time in the postanesthesia care unit between the groups. Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS) in the SSA and GA groups, respectively. In the hospital, the pain scores were significantly (P < 0.001) lower in the SSA group compared with the GA group and the need for postoperative opioids was significantly (P = 0.008) larger after GA. The incidence of postoperative nausea and vomiting was 0% versus 19% in the SSA and GA groups (P = 0.024), respectively. We conclude that for outpatients undergoing knee arthroscopy, SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane.

Adult↗
PubMedDate not supplied

Reversal of the central effects of midazolam by intravenous flumazenil after general anesthesia and use of a long-acting opioid in hospitalized patients: report of a multicenter double-blind clinical study. The Flumazenil in General Anesthesia in Hospitalized Patients Study Group II.

A double-blind clinical trial was conducted to evaluate the efficacy and safety of flumazenil, a benzodiazepine antagonist, in 146 hospitalized patients, who had had general anesthesia induced by midazolam and a long-acting opioid. Ninety-eight patients received flumazenil and 48 received placebo. Administered postoperatively at a mean intravenous dose of 0.84 mg (range: 0.2 mg to 1 mg), flumazenil reversed benzodiazepine-induced sedation to a greater extent than did placebo. At 5 minutes posttreatment, 61 (76%) of 80 flumazenil-treated patients and 7 (18%) of 40 placebo-treated patients had attained a score of 4 or 5 on the Observer's Assessment of Alertness/Sedation Scale, indicating that they were drowsy or fully awake and alert. This level of arousal was maintained for the full 180-minute posttreatment assessment period in 79% of flumazenil-treated patients. Between-group differences in mean change from baseline in level of alertness were statistically significant (P < 0.01) until 60 minutes posttreatment, when the spontaneous recovery of placebo-treated patients resulted in declining intergroup differences. The global efficacy rating (based on the physician's general impression of the effectiveness of the reversal of sedation 5 minutes after test drug administration) was good or excellent in 64 (80%) of the 80 flumazenil-treated patients and 5 (13%) of the 40 placebo-treated patients evaluated. Flumazenil, compared with placebo, was not associated with an increased frequency of operative-site pain, and no serious adverse effects of this benzodiazepine antagonist were reported. The most frequent adverse experiences in both treatment groups were nausea, shivering, and operative-site pain. Vomiting, dizziness, and injection-site reactions were also reported in > or = 5% of patients treated with flumazenil.

Adult↗
PubMed2004

Perioperative management for one day hospital admission: regional anesthesia is better than general anesthesia.

The past ten years have showed real and considerable growth in the number and complexity of ambulatory surgeries. The remaining real problems are the postoperative pain and the adverse effects due to parenteral opioids promoting hospital readmissions and increasing costs. This events limit the expansion of outpatient surgery. Regional anesthesia techniques such as spinal anesthesia and peripheral nerve blocks are ideal techniques for one day hospital admissions surgical procedures. It is now fully demonstrated that these techniques allowed rapid and complete anesthetic blocks, a limitation of adeverses events and unplanned hospital admissions and increased the quality of prolonged optimal postoperative pain relief if continuous peripheral nerve blocks are used.

Ambulatory Surgical Procedures↗
PubMed1994

Epidural anesthesia impairs both central and peripheral thermoregulatory control during general anesthesia.

BACKGROUND: The authors tested the hypotheses that: (1) the vasoconstriction threshold during combined epidural/general anesthesia is less than that during general anesthesia alone; and (2) after vasoconstriction, core cooling rates during combined epidural/general anesthesia are greater than those during general anesthesia alone. Vasoconstriction thresholds and heat balance were evaluated under controlled circumstances in volunteers, whereas the clinical importance of intraoperative thermoregulatory vasoconstriction was evaluated in patients. METHODS: Five volunteers were each evaluated twice. On one of the randomly ordered days, epidural anesthesia (approximately T9 dermatomal level) was induced and maintained with 2-chloroprocaine. On both study days, general anesthesia was induced and maintained with isoflurane (0.7% end-tidal concentration), and core hypothermia was induced by surface cooling and continued for at least 1 h after fingertip vasoconstriction was observed. Patients undergoing colorectal surgery were randomly assigned to combined epidural/enflurane anesthesia (n = 13) or enflurane alone (n = 13). In appropriate patients, epidural anesthesia was maintained by an infusion of bupivacaine. The core temperature that triggered fingertip vasoconstriction identified the threshold. RESULTS: In the volunteers, the vasoconstriction threshold was 36.0 +/- 0.2 degrees C during isoflurane anesthesia alone, but significantly less, 35.1 +/- 0.7 degrees C, during combined epidural/isoflurane anesthesia. Cutaneous heat loss and the rates of core cooling were similar 30 min before vasoconstriction with and without epidural anesthesia. In the 30 min after vasoconstriction, heat loss decreased 33 +/- 13 W when the volunteers were given isoflurane alone, but only 8 +/- 16 W during combined epidural/isoflurane anesthesia. Similarly, the core cooling rates in the 30 min after vasoconstriction were significantly greater during combined epidural/isoflurane anesthesia (0.8 +/- 0.2 degrees C/h) than during isoflurane alone (0.2 +/- 0.1 degrees C/h). In the patients, end-tidal enflurane concentrations were slightly, but significantly, less in the patients given combined epidural/enflurane anesthesia (0.6 +/- 0.2% vs. 0.8 +/- 0.2%). Nonetheless, the vasoconstriction threshold was 34.5 +/- 0.6 degrees C in the epidural/enflurane group, which was significantly less than that in the other patients, 35.6 +/- 0.8 degrees C. When the study ended after 3 h of anesthesia, patients given combined epidural/enflurane anesthesia were 1.2 degrees C more hypothermic than those given general anesthesia alone. The rate of core cooling during the last hour of the study was 0.4 +/- 0.2 degrees C/h during combined epidural/enflurane anesthesia, but only 0.1 +/- 0.3 degrees C/h during enflurane alone. CONCLUSIONS: These data indicate that epidural anesthesia reduces the vasoconstriction threshold during general anesthesia. Furthermore, the markedly reduced rate of core cooling during general anesthesia alone illustrates the importance of leg vasoconstriction in maintaining core temperature.

Adolescent↗
PubMedDate not supplied

[Combined caudal and general anesthesia in clubfoot surgery].

In a retrospective study we analysed the effect of caudal epidural anesthesia combined with general anesthesia on requirement for intraoperative narcotics and postoperative analgesics in children undergoing surgical release of congenital clubfoot. In 20 children (mean age at day of surgery 4,7 months) general anesthesia was supplemented by caudal epidural anesthesia, controls (20 children, mean age 4,3 months) received general anesthesia only. Compared to controls, the amount of narcotics was significantly reduced in the caudal epidural group (1,1 Vol% compared to 1,6 Vol% Isofluran). As well the use of analgesics in the postoperative phase was decreased from 112,5 mg to 56,3 mg Paracetamol. The children in the caudal epidural group recovered from anesthesia more comfortably. No complications occurred in either group. Our results show, that general anesthesia combined with caudal epidural anesthesia is more suitable for surgical release of congenital clubfoot than the exclusive use of general anesthesia.

Analgesics↗
PubMed2001

Incidence of oral tissue trauma after the administration of general anesthesia.

BACKGROUND: Administration of general anesthesia necessitates certain amounts of manipulation or instrumentation within the mouth that may cause some oral tissue injuries. The purpose of this study was to determine the incidence of oral tissue trauma after receiving general anesthesia. Some possible risk factors were explored. METHODS: Four hundred and four adult patients receiving surgical procedures under general anesthesia facilitated by endotracheal intubation were included in this prospective survey. In each patient detailed oral and dental conditions were evaluated and recorded by an oral surgeon before and after operation. The extent of oral tissue trauma were computed and the type and character of the injury were recorded. RESULTS: Twenty-eight patients (6.9%) were found to sustain various degrees of oral trauma that included soft tissue laceration, tooth fracture, prosthesis damage, tooth avulsion, ecchymosis and numbness of tongue. Preexistence of missing tooth, crown, and residual root were some possible risk factors that might predispose to complication. CONCLUSIONS: Oral tissue trauma as it seems to be a common anesthetic complication that should be considered as a recognized hazard of general anesthesia. Understanding and recognizing oral anatomical condition and pathological change before anesthesia may help the anesthesiologists in preventing oral and dental complications and thus to avoid legal suits.

Adolescent↗
PubMed2006

A randomized trial of local anesthesia with intravenous sedation vs general anesthesia for the vaginal correction of pelvic organ prolapse.

The purpose of this study is to compare the feasibility of local anesthesia with IV sedation versus general anesthesia for vaginal correction of pelvic organ prolapse. Patients with pelvic organ prolapse who were scheduled for an anterior or posterior colporrhaphy, or an obliterative procedure, and who did not have a contraindication or preference to type of anesthesia were randomized to one of the two anesthesia groups. Nineteen patients were randomized to the general group and 21 patients were randomized to the local group. Mean operating room, anesthesia, and surgical time were similar in each group, and 10 patients in the local group bypassed the recovery room. Requests and doses of antiemetics, postoperative verbal numerical pain scores and length of hospital stay were similar between the two groups. Mean recovery room and total hospital costs were significantly lower in the local group. Local anesthesia with IV sedation is a feasible alternative for vaginal surgery to correct pelvic organ prolapse.

Aged↗
PubMed1983

Thromboembolism after total hip replacement: role of epidural and general anesthesia.

The effects of continuous epidural anesthesia and of general anesthesia on the incidence of thromboembolism following total hip replacement were studied. Sixty patients were randomly allotted to one of two groups receiving either epidural or general anesthesia. Epidural anesthesia (N = 30) consisted of 0.5% bupivacaine with epinephrine intraoperatively; for pain relief in the postoperative period (24 h), 0.25% bupivacaine with epinephrine was given every 3 h. General anesthesia (N = 30) consisted of controlled ventilation with N2O-O2 and intravenous fentanyl and pancuronium bromide; postoperatively, narcotic analgesics were given intramuscularly on demand for pain relief. Significantly lower frequencies were found following epidural anesthesia than after general anesthesia in deep venous thrombosis involving the popliteal and femoral veins (13% and 67%, respectively), deep venous thrombosis involving both calf and thigh veins (40% and 77%), and pulmonary embolism (10% and 33%). Possible explanations for these differences include increased circulation in the lower extremities, less tendency for intravascular clotting to occur, and more efficient fibrinolysis in association with continuous epidural anesthesia. The decrease in blood loss associated with epidural anesthesia with lower transfusion requirements also might play a role. Epidural analgesia prolonged into the postoperative period, in addition to other appropriate thromboprophylactic measures, should be of value in patients undergoing operations associated with a high risk of thromboembolic complications.

Aged↗
PubMed2006

Cervical epidural anesthesia: a safe alternative to general anesthesia for patients undergoing cancer breast surgery.

BACKGROUND: General anesthesia (GA) is the standard anesthesia for patients undergoing modified radical mastectomy (MRM) for breast cancer. Cervical epidural anesthesia (CEA) is practiced less often because of its reported complications. This prospective study aimed to evaluate the safety and efficacy of CEA as an anesthetic technique for MRM. PATIENTS AND METHODS: Fifty breast cancer patients with ASA (American Society of Anesthesiologists) grade I or II underwent MRM under CEA from September 2004 to January 2006. Anesthesia was induced with 10 ml of 1% lignocaine; adrenaline was administered through an 18-gauge catheter in C(6)-C(7) or C(7)-T(1) epidural space. Postoperative analgesia was maintained with 0.125% bupivacaine through the epidural catheter. RESULTS: In 49 (98%) patients surgery was conducted smoothly under CEA with good analgesia. 44 patients were awake during surgery. Five patients had to be given intravenous sedation with midazolam, and in one case the procedure was terminated after accidental dura puncture. There were no clinically significant variations in perioperative pulse and respiratory rate, and there was no fall in mean arterial blood pressure during the procedure. The mean preoperative anesthesia time and total cost of the procedure was 20.36 + 2.75 minutes and 12.19 + 2.2 pound, respectively. All patients were started on a liquid diet and mobilized 4 hours after surgery. CONCLUSIONS: Cervical epidural anesthesia is a safe alternative to GA and was preferred by our patients because of its lower cost and reduced perioperative morbidity.

Anesthesia, Epidural↗
PubMed2004

Modafinil improves recovery after general anesthesia.

UNLABELLED: Recovery from general anesthesia often involves residual sedation, drowsiness, fatigue, and lack of energy that may last hours to days. Modafinil is a wakefulness-promoting drug approved for patients with excessive daytime sleepiness associated with narcolepsy. We evaluated the effect of single doses of modafinil (200 mg) and placebo in patients recovering from general anesthesia. Thirty-four subjects participated in this prospective, randomized, double-blind study approved by our IRB. Preoperatively, patients were asked to rate various symptoms they had experienced over the previous 24-h using a verbal analog scale (VAS) of 0 to 10 as well as discrete scale when indicated. Postoperatively, once the patient was able to tolerate oral intake and met our institutional discharge criteria, the study drug (modafinil 200 mg or placebo) was administered with a sip of water. Patients were contacted 24 (1) hours after dosing to evaluate postdischarge symptoms. Patients in the placebo group reported significantly more postoperative fatigue (4.8 [3.3] versus 1.4 [1.8]), exhaustion (4.3 [3.3] versus 2.4 [3.1]), or degree of feeling worn out (4.7 [3.6] versus 2.9 [2.4]). Significantly more patients reported moderate to severe fatigue in the placebo group (65% versus 12%). Two major themes of "alertness" and "energy" were expressed by 71% of the patients receiving modafinil versus 18% of those receiving placebo. Patients recovering from general anesthesia can significantly benefit from modafinil. IMPLICATIONS: Modafinil significantly reduces fatigue and improves feelings of alertness and energy in postoperative patients. Patients recovering from general anesthesia can significantly benefit from modafinil administration.

Adolescent↗
PubMed1997

Comparison of general anesthesia with and without lumbar epidural for total hip arthroplasty: effects of epidural block on hip arthroplasty.

STUDY OBJECTIVES: To determine whether lumbar epidural anesthesia, when combined with general anesthesia, decreases perioperative blood loss, the incidence of postoperative deep vein thrombosis (DVT), cardiac dysrhythmias, and ischemia in patients undergoing total hip arthroplasty (THA). DESIGN: Randomized, controlled study. SETTING: A university hospital. PATIENTS: 37 ASA physical status I, II, and III patients, undergoing elective THA. INTERVENTION: Patients were divided into two statistically comparable groups: Group GA = general anesthesia; Group CEGA = general anesthesia plus lumbar epidural anesthesia. All patients had 48-hour perioperative Holter monitoring, applied on admission, the day prior to surgery. In both groups, general anesthesia was induced with thiopental sodium and muscle relaxant, and maintained with oxygen, nitrous oxide, isoflurane, opioid, and muscle relaxant. Group B received lumbar epidural anesthesia with 10 ml 0.5% bupivacaine with 1:200,000 epinephrine prior to anesthesia induction. Blood loss was measured by suction bottle contents, sponge weights, and collection drainage. DVT was assessed with postoperative leg scanning, plethysmography, and venogram. MEASUREMENTS AND MAIN RESULTS: Intraoperative blood loss was less after combined epidural-general anesthesia (663.8 ml +/- 299.0 ml) than after general anesthesia alone (1,259.2 ml +/- 366.0 ml). The difference was found to be statistically significant (p < 0.00005). No difference was found between the two groups in postoperative blood loss, incidence of DVT, cardiac dysrhythmias, or ischemia. CONCLUSION: Combined regional-general anesthesia decreases intraoperative blood loss in THA, and thereby offers an advantage over general anesthesia alone.

Aged↗
PubMed2000

Ondansetron given before induction of anesthesia reduces shivering after general anesthesia.

UNLABELLED: The neurotransmitter pathways involved in the mechanism of postanesthetic shivering (PAS) are poorly understood. Meperidine, clonidine, and physostigmine are all effective treatments, indicating that opioid, alpha(2)-adrenergic, and anticholinergic systems are probably involved. We investigated the effect of ondansetron, a 5-HT(3) antagonist used to treat postoperative nausea and vomiting, on intraoperative core and peripheral temperatures and PAS. Eighty-two patients (age, 18-60 yr) undergoing orthopedic, general, or urological surgery were randomized into three groups in this double-blinded, placebo-controlled, study: Group O4 (n = 27) received ondansetron 4 mg IV, Group O8 (n = 27) received ondansetron 8 mg IV, and Group C (n = 28) received saline IV immediately before the anesthetic induction. Core (tympanic) and fingertip temperature (dorsum of middle finger) were recorded. Anesthesia was induced with IV fentanyl 1 microg/kg and propofol 2.0-2.5 mg/kg and maintained with 1 minimum alveolar anesthetic concentration isoflurane in 70% nitrous oxide/oxygen. The occurrence of shivering was documented clinically during recovery by nursing staff, who were unaware of the group assignment. PAS occurred in 16 of 28 (57%) patients in Group C, compared with 9 of 27 (33%) in Group O4 (P = 0.13) and 4 of 27 (15%) patients in Group O8 (P = 0.003). Within each group, core temperature decreased and peripheral temperature increased significantly, but there were no significant differences among the groups at any time interval. We conclude that ondansetron 8 mg IV given during the induction of anesthesia prevents PAS without affecting the core-to-peripheral redistribution of heat during general anesthesia. This suggests that serotonergic pathways have a role in the regulation of PAS. IMPLICATIONS: In a randomized, double-blinded, placebo-controlled, clinical study, ondansetron 8 mg IV, given just before the induction, reduced the incidence of postanesthetic shivering compared with saline. The anticipated core-to-peripheral redistribution of body temperature during general anesthesia was not affected. This implies that ondansetron probably acts by a central inhibitory mechanism, and that 5-hydroxytryptaminergic pathways have a role in regulating postanesthetic shivering.

Adult↗