1
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Qiao WP, Haskins SC, Liu J. Racial and ethnic disparities in regional anesthesia in the United States: A narrative review. J Clin Anesth 2024; 94:111412. [PMID: 38364694 DOI: 10.1016/j.jclinane.2024.111412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 02/01/2024] [Accepted: 02/08/2024] [Indexed: 02/18/2024]
Abstract
BACKGROUND Racial and ethnic disparities exist in the delivery of regional anesthesia in the United States. Anesthesiologists have ethical and economic obligations to address existing disparities in regional anesthesia care. OBJECTIVES Current evidence of racial and ethnic disparities in regional anesthesia utilization in adult patients in the United States is presented. Potential contributors and solutions to racial disparities are also discussed. EVIDENCE REVIEW Literature search was performed for studies examining racial and ethnic disparities in utilization of regional anesthesia, including neuraxial anesthesia and/or peripheral nerve blocks. FINDINGS While minoritized patients are generally less likely to receive regional anesthesia than white patients, the pattern of disparities for different racial/ethnic groups and for types of regional anesthetics can be complex and varied. Contributors to racial/ethnic disparities in regional anesthesia span hospital, provider, and patient-level factors. Potential solutions include standardization of regional anesthetic practices via Enhanced Recovery After Surgery (ERAS) pathways, increasing patient education, health literacy, language translation services, and improving diversity and cultural competency in the anesthesiology workforce. CONCLUSION Racial and ethnic disparities in regional anesthesia exist. Contributors and solutions to these disparities are multifaceted. Much work remains within the subspecialty of regional anesthesia to identify and address such disparities.
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Affiliation(s)
- William P Qiao
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, United States of America; Department of Anesthesiology, Weill Cornell Medical College, New York, NY, United States of America.
| | - Stephen C Haskins
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, United States of America; Department of Anesthesiology, Weill Cornell Medical College, New York, NY, United States of America.
| | - Jiabin Liu
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, United States of America; Department of Anesthesiology, Weill Cornell Medical College, New York, NY, United States of America.
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2
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Theophanous RG, Chow VW, Convissar DL, Haskins SC, Jones RA, P Kalagara HK, Bronshteyn YS. Point-Of-Care Ultrasound Screening for Proximal Lower Extremity Deep Venous Thrombosis. J Vis Exp 2023. [PMID: 36847361 DOI: 10.3791/64601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
Abstract
Acute lower extremity deep venous thrombosis (DVT) is a serious vascular disorder that requires accurate and early diagnosis to prevent life-threatening sequelae. While whole leg compression ultrasound with color and spectral Doppler is commonly performed in radiology and vascular labs, point-of-care ultrasound (POCUS) is becoming more common in the acute care setting. Providers appropriately trained in focused POCUS can perform a rapid bedside examination with high sensitivity and specificity in critically ill patients. This paper describes a simplified yet validated approach to POCUS by describing a three-zone protocol for lower extremity DVT POCUS image acquisition. The protocol explains the steps in obtaining vascular images at six compression points in the lower extremity. Beginning at the level of the proximal thigh and moving distally to the popliteal space, the protocol guides the user through each of the compression points in a stepwise manner: from the common femoral vein to the femoral and deep femoral vein bifurcation, and, finally, to the popliteal vein. Further, a visual aid is provided that may assist providers during real-time image acquisition. The goal in presenting this protocol is to help make proximal lower extremity DVT exams more accessible and efficient for POCUS users at the patient's bedside.
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Affiliation(s)
| | - Vinca W Chow
- Department of Anesthesiology, Dartmouth-Hitchcock Medical Center
| | | | - Stephen C Haskins
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery; Department of Anesthesiology, Weill-Cornell Medical College
| | - Robert A Jones
- Department of Emergency Medicine, MetroHealth Medical Center/Case Western Reserve University
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3
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YaDeau JT, Mayman DJ, Jules-Elysee KM, Lin Y, Padgett DE, DeMeo DA, Gbaje EC, Goytizolo EA, Kim DH, Sculco TP, Kahn RL, Haskins SC, Brummett CM, Zhong H, Westrich G. Effect of Duloxetine on Opioid Use and Pain After Total Knee Arthroplasty: A Triple-Blinded Randomized Controlled Trial. J Arthroplasty 2022; 37:S147-S154. [PMID: 35346549 DOI: 10.1016/j.arth.2022.02.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 02/01/2022] [Accepted: 02/07/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Duloxetine, a serotonin-norepinephrine dual reuptake inhibitor, may improve analgesia after total knee arthroplasty (TKA). Previous studies had one primary outcome, did not consistently use multimodal analgesia, and used patient-controlled analgesia devices, potentially delaying discharge. We investigated whether duloxetine would reduce opioid consumption or pain with ambulation. METHODS A total of 160 patients received 60 mg duloxetine or placebo daily, starting from the day of surgery and continuing 14 days postoperatively. Patients received neuraxial anesthesia, peripheral nerve blocks, acetaminophen, nonsteroidal anti-inflammatory drugs, and oral opioids as needed. The dual primary outcomes were Numeric Rating Scale (NRS) scores with movement on postoperative days 1, 2, and 14, and cumulative opioid consumption surgery through postoperative day 14. RESULTS Duloxetine was noninferior to placebo for both primary outcomes and was superior to placebo for opioid consumption. Opioid consumption (mean ± SD) was 288 ± 226 mg OME [94, 385] vs 432 ± 374 [210, 540] (duloxetine vs placebo) P = .0039. Pain scores on POD14 were 4.2 ± 2.0 vs 4.8 ± 2.2 (duloxetine vs placebo) P = .018. Median satisfaction with pain management was 10 (8, 10) and 8 (7, 10) (duloxetine vs placebo) P = .046. Duloxetine reduced interference by pain with walking, normal work, and sleep. CONCLUSION The 29% reduction in opioid use corresponds to 17 fewer pills of oxycodone, 5 mg, and was achieved without increasing pain scores. Considering the ongoing opioid epidemic, duloxetine can be used to reduce opioid usage after knee arthroplasty in selected patients that can be appropriately monitored for potential side effects of the medication.
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Affiliation(s)
- Jacques T YaDeau
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY; Department of Anesthesiology, Weill Cornell Medicine, New York, NY
| | - David J Mayman
- Department of Orthopedic Surgery (Adult Reconstruction and Joint Replacement Service), Hospital for Special Surgery, New York, NY
| | - Kethy M Jules-Elysee
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY; Department of Anesthesiology, Weill Cornell Medicine, New York, NY
| | - Yi Lin
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY; Department of Anesthesiology, Weill Cornell Medicine, New York, NY
| | - Douglas E Padgett
- Department of Orthopedic Surgery (Adult Reconstruction and Joint Replacement Service), Hospital for Special Surgery, New York, NY
| | - Danya A DeMeo
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY
| | - Ejiro C Gbaje
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY
| | - Enrique A Goytizolo
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY; Department of Anesthesiology, Weill Cornell Medicine, New York, NY
| | - David H Kim
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY; Department of Anesthesiology, Weill Cornell Medicine, New York, NY
| | - Thomas P Sculco
- Department of Orthopedic Surgery (Adult Reconstruction and Joint Replacement Service), Hospital for Special Surgery, New York, NY
| | - Richard L Kahn
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY; Department of Anesthesiology, Weill Cornell Medicine, New York, NY
| | - Stephen C Haskins
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY; Department of Anesthesiology, Weill Cornell Medicine, New York, NY
| | - Chad M Brummett
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI
| | - Haoyan Zhong
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY
| | - Geoffrey Westrich
- Department of Orthopedic Surgery (Adult Reconstruction and Joint Replacement Service), Hospital for Special Surgery, New York, NY
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4
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Bronshteyn YS, Anderson TA, Badakhsh O, Boublik J, Brady MBW, Charnin JE, Coker BJ, Deriy LB, Hardman HD, Haskins SC, Hollon M, Hsia HLJ, Neelankavil JP, Panzer OPF, Perlas A, Ramsingh D, Sharma A, Shore-Lesserson LJ, Zimmerman JM. Diagnostic Point-of-Care Ultrasound: Recommendations From an Expert Panel. J Cardiothorac Vasc Anesth 2021; 36:22-29. [PMID: 34059438 DOI: 10.1053/j.jvca.2021.04.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 03/28/2021] [Accepted: 04/10/2021] [Indexed: 12/31/2022]
Abstract
Diagnostic point-of-care ultrasound (PoCUS) has emerged as a powerful tool to help anesthesiologists guide patient care in both the perioperative setting and the subspecialty arenas. Although anesthesiologists can turn to guideline statements pertaining to other aspects of ultrasound use, to date there remains little in the way of published guidance regarding diagnostic PoCUS. To this end, in 2018, the American Society of Anesthesiologists chartered an ad hoc committee consisting of 23 American Society of Anesthesiologists members to provide recommendations on this topic. The ad hoc committee convened and developed a committee work product. This work product was updated in 2021 by an expert panel of the ad hoc committee to produce the document presented herein. The document, which represents the consensus opinion of a group of practicing anesthesiologists with established expertise in diagnostic ultrasound, addresses the following issues: (1) affirms the practice of diagnostic PoCUS by adequately trained anesthesiologists, (2) identifies the scope of practice of diagnostic PoCUS relevant to anesthesiologists, (3) suggests the minimum level of training needed to achieve competence, (4) provides recommendations for how diagnostic PoCUS can be used safely and ethically, and (5) provides broad guidance about diagnostic ultrasound billing.
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Affiliation(s)
- Yuriy S Bronshteyn
- Duke University School of Medicine, Duke University Health System, Durham Veterans Health Administration, Durham, NC.
| | | | - Orode Badakhsh
- University of California Davis Medical Center, Sacramento, CA
| | - Jan Boublik
- Stanford University School of Medicine, Stanford, CA
| | | | - Jonathan E Charnin
- Mayo Clinic, Rochester, MN, University of Alabama at Birmingham, Birmingham, AL
| | - Bradley J Coker
- Mayo Clinic, Rochester, MN, University of Alabama at Birmingham, Birmingham, AL
| | - Lev B Deriy
- Department of Anesthesiology and Critical Care, University of New Mexico, Albuquerque, NM
| | - H David Hardman
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Stephen C Haskins
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY; Department of Anesthesiology, Weill-Cornell Medical College, New York, NY
| | - McKenzie Hollon
- Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA
| | - Hung-Lun John Hsia
- Duke University School of Medicine, Duke University Health System, Durham Veterans Health Administration, Durham, NC
| | | | - Oliver P F Panzer
- Columbia University College of Physicians and Surgeons, New York, NY
| | - Anahi Perlas
- Department of Anesthesiology and Pain Management, Toronto Western Hospital, University of Toronto, Toronto, Canada
| | - Davinder Ramsingh
- Department of Anesthesiology, Loma Linda University Medical Center, Loma Linda, CA
| | - Archit Sharma
- University of Iowa Carver College of Medicine, Iowa City, IA
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5
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Haskins SC, Bronshteyn Y, Perlas A, El-Boghdadly K, Zimmerman J, Silva M, Boretsky K, Chan V, Kruisselbrink R, Byrne M, Hernandez N, Boublik J, Manson WC, Hogg R, Wilkinson JN, Kalagara H, Nejim J, Ramsingh D, Shankar H, Nader A, Souza D, Narouze S. American Society of Regional Anesthesia and Pain Medicine expert panel recommendations on point-of-care ultrasound education and training for regional anesthesiologists and pain physicians-part II: recommendations. Reg Anesth Pain Med 2021; 46:1048-1060. [PMID: 33632777 DOI: 10.1136/rapm-2021-102561] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 02/04/2021] [Indexed: 12/21/2022]
Abstract
Point-of-care ultrasound (POCUS) is a critical skill for all regional anesthesiologists and pain physicians to help diagnose relevant complications related to routine practice and guide perioperative management. In an effort to inform the regional anesthesia and pain community as well as address a need for structured education and training, the American Society of Regional Anesthesia and Pain Medicine Society (ASRA) commissioned this narrative review to provide recommendations for POCUS. The recommendations were written by content and educational experts and were approved by the guidelines committee and the Board of Directors of the ASRA. In part II of this two-part series, learning goals and objectives were identified and outlined for achieving competency in the use of POCUS, specifically, airway ultrasound, lung ultrasound, gastric ultrasound, the focus assessment with sonography for trauma exam, and focused cardiac ultrasound, in the perioperative and chronic pain setting. It also discusses barriers to POCUS education and training and proposes a list of educational resources. For each POCUS section, learning goals and specific skills were presented in the Indication, Acquisition, Interpretation, and Medical decision-making framework.
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Affiliation(s)
- Stephen C Haskins
- Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York, USA .,Anesthesiology, Weill Cornell Medical College, New York, New York, USA
| | - Yuriy Bronshteyn
- Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Anahi Perlas
- Anesthesia and Pain Management, Toronto Western Hospital, Toronto, Ontario, Canada
| | | | - Joshua Zimmerman
- Anesthesiology, University of Utah Health, Salt Lake City, Utah, USA
| | - Marcos Silva
- Anesthesia and Pain Management, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Karen Boretsky
- Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Vincent Chan
- Anesthesia and Pain Management, Toronto Western Hospital, Toronto, Ontario, Canada
| | | | - Melissa Byrne
- Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Nadia Hernandez
- Anesthesiology, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Jan Boublik
- Anesthesiology, Stanford Hospital and Clinics, Stanford, California, USA
| | - William Clark Manson
- Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Rosemary Hogg
- Anaesthesia, Belfast Health and Social Care Trust, Belfast, UK
| | - Jonathan N Wilkinson
- Intensive Care and Anaesthesia, Northampton General Hospital, Northampton, Northamptonshire, UK
| | | | - Jemiel Nejim
- Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York, USA.,Anesthesiology, Weill Cornell Medical College, New York, New York, USA
| | - Davinder Ramsingh
- Anesthesiology, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Hariharan Shankar
- Anesthesiology, Clement Zablocki VA Medical Center/Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Antoun Nader
- Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Dmitri Souza
- Center for Pain Medicine, Western Reserve Hospital, Cuyahoga Falls, Ohio, USA
| | - Samer Narouze
- Center for Pain Medicine, Western Reserve Hospital, Cuyahoga Falls, Ohio, USA
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6
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Haskins SC, Bronshteyn Y, Perlas A, El-Boghdadly K, Zimmerman J, Silva M, Boretsky K, Chan V, Kruisselbrink R, Byrne M, Hernandez N, Boublik J, Manson WC, Hogg R, Wilkinson JN, Kalagara H, Nejim J, Ramsingh D, Shankar H, Nader A, Souza D, Narouze S. American Society of Regional Anesthesia and Pain Medicine expert panel recommendations on point-of-care ultrasound education and training for regional anesthesiologists and pain physicians-part I: clinical indications. Reg Anesth Pain Med 2021; 46:1031-1047. [PMID: 33632778 DOI: 10.1136/rapm-2021-102560] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 02/04/2021] [Indexed: 12/20/2022]
Abstract
Point-of-care ultrasound (POCUS) is a critical skill for all regional anesthesiologists and pain physicians to help diagnose relevant complications related to routine practice and guide perioperative management. In an effort to inform the regional anesthesia and pain community as well as address a need for structured education and training, the American Society of Regional Anesthesia and Pain Medicine (ASRA) commissioned this narrative review to provide recommendations for POCUS. The guidelines were written by content and educational experts and approved by the Guidelines Committee and the Board of Directors of the ASRA. In part I of this two-part series, clinical indications for POCUS in the perioperative and chronic pain setting are described. The clinical review addresses airway ultrasound, lung ultrasound, gastric ultrasound, the focus assessment with sonography for trauma examination and focused cardiac ultrasound for the regional anesthesiologist and pain physician. It also provides foundational knowledge regarding ultrasound physics, discusses the impact of handheld devices and finally, offers insight into the role of POCUS in the pediatric population.
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Affiliation(s)
- Stephen C Haskins
- Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York, USA .,Anesthesiology, Weill Cornell Medical College, New York, New York, USA
| | - Yuriy Bronshteyn
- Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Anahi Perlas
- Anesthesiology and Pain Management, Toronto Western Hospital, Toronto, Ontario, Canada
| | | | - Joshua Zimmerman
- Anesthesiology, University of Utah Health, Salt Lake City, Utah, USA
| | - Marcos Silva
- Anesthesiology and Pain Management, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Karen Boretsky
- Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Vincent Chan
- Anesthesiology and Pain Management, Toronto Western Hospital, Toronto, Ontario, Canada
| | | | - Melissa Byrne
- Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Nadia Hernandez
- Anesthesiology, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Jan Boublik
- Anesthesiology, Stanford Hospital and Clinics, Stanford, California, USA
| | - William Clark Manson
- Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Rosemary Hogg
- Anaesthesia, Belfast Health and Social Care Trust, Belfast, UK
| | - Jonathan N Wilkinson
- Intensive Care and Anaesthesia, Northampton General Hospital, Northampton, Northamptonshire, UK
| | | | - Jemiel Nejim
- Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York, USA.,Anesthesiology, Weill Cornell Medical College, New York, New York, USA
| | - Davinder Ramsingh
- Anesthesiology, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Hariharan Shankar
- Anesthesiology, Clement Zablocki VA Medical Center/Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Antoun Nader
- Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Dmitri Souza
- Center for Pain Medicine, Western Reserve Hospital, Cuyahoga Falls, Ohio, USA
| | - Samer Narouze
- Center for Pain Medicine, Western Reserve Hospital, Cuyahoga Falls, Ohio, USA
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7
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Wahal C, Baratta J, Beausang D, Weber M, Torjman MC, Haskins SC, Schwenk ES. Pulp fiction? A point-of-care gastric ultrasound analysis of gastric contents after ingestion of orange juice with and without pulp. Reg Anesth Pain Med 2020; 46:280-281. [PMID: 33077430 DOI: 10.1136/rapm-2020-101771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 09/14/2020] [Accepted: 09/17/2020] [Indexed: 11/03/2022]
Affiliation(s)
- Christopher Wahal
- Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Jaime Baratta
- Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - David Beausang
- Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Marissa Weber
- Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Marc C Torjman
- Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Stephen C Haskins
- Anesthesiology, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
| | - Eric S Schwenk
- Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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8
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Kars MS, Gomez Morad A, Haskins SC, Boublik J, Boretsky K. Point-of-care ultrasound for the pediatric regional anesthesiologist and pain specialist: a technique review. Reg Anesth Pain Med 2020; 45:985-992. [DOI: 10.1136/rapm-2020-101341] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 08/04/2020] [Accepted: 08/08/2020] [Indexed: 01/11/2023]
Abstract
Point-of-care ultrasound (PoCUS) has been well described for adult perioperative patients; however, the literature on children remains limited. Regional anesthesiologists have gained interest in expanding their clinical repertoire of PoCUS from regional anesthesia to increasing numbers of applications. This manuscript reviews and highlights emerging PoCUS applications that may improve the quality and safety of pediatric care.In infants and children, lung and airway PoCUS can be used to identify esophageal intubation, size airway devices such as endotracheal tubes, and rule in or out a pulmonary etiology for clinical decompensation. Gastric ultrasound can be used to stratify aspiration risk when nil-per-os compliance and gastric emptying are uncertain. Cardiac PoCUS imaging is useful to triage causes of undifferentiated hypotension or tachycardia and to determine reversible causes of cardiac arrest. Cardiac PoCUS can assess for pericardial effusion, gross ventricular systolic function, cardiac volume and filling, and gross valvular pathology. When PoCUS is used, a more rapid institution of problem-specific therapy with improved patient outcomes is demonstrated in the pediatric emergency medicine and critical care literature.Overall, PoCUS saves time, expedites the differential diagnosis, and helps direct therapy when used in infants and children. PoCUS is low risk and should be readily accessible to pediatric anesthesiologists in the operating room.
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9
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Affiliation(s)
- Stephen C Haskins
- From the Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York.,Departments of Anesthesiology
| | - Stavros G Memtsoudis
- From the Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York.,Departments of Anesthesiology.,Health Policy and Research, Weill Cornell Medical College, New York, New York
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10
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Haskins SC, Fiasconaro M, Wilson L, Poeran J, Liu J, Memtsoudis S. Ultrasound guidance for peripheral nerve blocks: an observational trend study of national data. Reg Anesth Pain Med 2020; 45:rapm-2019-101113. [PMID: 32054667 DOI: 10.1136/rapm-2019-101113] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 12/11/2019] [Accepted: 12/17/2019] [Indexed: 11/03/2022]
Affiliation(s)
- Stephen C Haskins
- Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, United States
- Anesthesiology, Weill-Cornell Medical College, New York, NY, United States
| | - Megan Fiasconaro
- Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, United States
| | - Lauren Wilson
- Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, United States
| | - Jashvant Poeran
- Orthopaedics/Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jiabin Liu
- Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, United States
- Anesthesiology, Weill-Cornell Medical College, New York, NY, United States
| | - Stavros Memtsoudis
- Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, United States
- Anesthesiology, Weill-Cornell Medical College, New York, NY, United States
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11
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Boublik J, Haskins SC. One small step for mankind, a big step for PoCUS. Reg Anesth Pain Med 2019; 45:93-94. [DOI: 10.1136/rapm-2019-100800] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 09/20/2019] [Accepted: 09/23/2019] [Indexed: 01/24/2023]
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12
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Manson WC, Kirksey M, Boublik J, Wu CL, Haskins SC. Focused assessment with sonography in trauma (FAST) for the regional anesthesiologist and pain specialist. Reg Anesth Pain Med 2019; 44:540-548. [DOI: 10.1136/rapm-2018-100312] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 02/10/2019] [Accepted: 02/20/2019] [Indexed: 11/04/2022]
Abstract
This article in our point-of-care ultrasound (PoCUS) series is dedicated to the role the focused assessment with sonography in trauma (FAST) exam plays for the regional anesthesiologist and pain specialists in the perioperative setting. The FAST exam is a well-established and extensively studied PoCUS exam in both surgical and emergency medicine literature with over 20 years demonstrating its benefit in identifying the presence of free fluid in the abdomen following trauma. However, only recently has the FAST exam been shown to be beneficial to the anesthesiologist in the perioperative setting as a means to identify the extravasation of free fluid into the abdomen from the hip joint following hip arthroscopy. In this article, we will describe how to obtain the basic FAST views (subcostal four-chamber view, perihepatic right upper quadrant view, perisplenic left upper quadrant view, and pelvic view in the longitudinal and short axis) as well as cover the relevant sonoanatomy. We will describe pathological findings seen with the FAST exam, primarily free fluid in the peritoneal space as well as in the pericardial sac. As is the case with any PoCUS skill, the application evolves with understanding and utilization by new clinical specialties. Although this article will provide clinical examples of where the FAST exam is beneficial to the regional anesthesiologist and pain specialist, it also serves as an introduction to this powerful PoCUS skill in order to encourage clinical practitioners to expand the application of the FAST exam within the scope of regional anesthesia and pain management practice.
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Haskins SC, Feldman D, Fields KG, Kirksey MA, Lien CA, Luu TH, Nejim JA, Osorio JA, Yang EI. Teaching a Point-of-Care Ultrasound Curriculum to Anesthesiology Trainees With Traditional Didactic Lectures or an Online E-Learning Platform: A Pilot Study. J Educ Perioper Med 2018; 20:E624. [PMID: 30510972 PMCID: PMC6257000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND Point-of-care ultrasonography (PoCUS) provides real-time, dynamic clinical evidence for providers to make potentially lifesaving medical decisions; however, these tools cannot be used effectively without appropriate training. Although there is always the option of traditional didactic methods, there has been a recent trend toward a "reverse classroom" web-based model using online e-learning modules. Our objective was to collect pilot data that would justify a future randomized controlled trial, comparing traditional didactics to an e-learning PoCUS curriculum for lung ultrasonography (LUS) and the focused assessment with sonography in trauma (FAST) exam. METHODS Anesthesiology interns, residents (CA 1-3), and fellow trainees enrolled in a LUS and FAST exam course and were randomized to receive didactic lectures or e-learning. Trainees completed knowledge pre- and posttests. Surveys were administered to gauge learning satisfaction. All trainees completed a hands-on-training (HOT) workshop. Image acquisition was assessed through practical tests before HOT, immediately after HOT, and 5 months later. RESULTS Eighteen trainees completed the study. There was no evidence of a difference in change in LUS knowledge test score from baseline to posttest between the e-learning and didactic groups (difference in median percentage point change [95 % CI]: 6.6 [-10.0, 23.2]; P = .411). There was no evidence of a difference in LUS knowledge posttest scores (difference in median percentage points [95% CI]: -0.9 [-4.8, 3.0]; P = .629), FAST knowledge posttest score (0 [incalculable]; P = .999), or post-HOT practical test score (-4.2 [-24.6, 16.3]; P = .672) between groups. There was no evidence of a difference in degree of satisfaction with learning experience between groups (odds ratios [95% CI]: 1.75 [0.31, 9.94]; P = .528). CONCLUSIONS There was no evidence of a difference between the e-learning and traditional didactic groups in learning or satisfaction outcomes. These results justify establishing an adequately powered, randomized controlled trial assessing the noninferiority of e-learning to traditional didactics for teaching LUS and FAST.
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Haskins SC, Zhao J, Nejim JA, Fields K, Garvin S, Dehipawala S, Beckman JD, Zhang A, Osorio JA, Tanaka C. Evaluation of Postgraduates Following Implementation of a Focus Assessed Transthoracic Echocardiography (FATE) Training Course-A Pilot Study. ACTA ACUST UNITED AC 2017; 8. [PMID: 29130022 PMCID: PMC5679106 DOI: 10.4172/2155-6148.1000763] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
At our institution, implementation of a formal training course in Basic Focus Assessed Transthoracic Echocardiography (FATE) was associated with an improvement in anesthesia trainees’ ability to obtain transthoracic echocardiography (TTE) images. Total image acquisition scores improved by a median (Q1, Q3) 9.1 (2.9,14.7) percentage points from pre-to post-hands-on FATE course (n=20; p=0.001). Participants who returned for a subsequent assessment 5 months following the course demonstrated a median (Q1, Q3) 18.0 (9.1,22.1) percentage point improvement from their pre-course total image acquisition scores (n=11; p=0.002). This pilot study established the feasibility of our program and results suggest that the basic FATE course can be used to teach trainees TTE quickly, effectively, and with significant retention.
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Affiliation(s)
| | - Jinhui Zhao
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Affiliation(s)
- Stephen C Haskins
- Department of Anesthesiology, Hospital for Special Surgery, New York, New York,
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Haskins SC, Nejim JA, Hong GJ. Post-Anesthesia Care. Anesth Analg 2017. [DOI: 10.1213/ane.0000000000002042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Haskins SC, Desai NA, Fields KG, Nejim JA, Cheng S, Coleman SH, Nawabi DH, Kelly BT. Diagnosis of Intraabdominal Fluid Extravasation After Hip Arthroscopy With Point-of-Care Ultrasonography Can Identify Patients at an Increased Risk for Postoperative Pain. Anesth Analg 2017; 124:791-799. [DOI: 10.1213/ane.0000000000001435] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Boublik J, Haskins SC. Pause Before You Rush to Use PAUSE! J Cardiothorac Vasc Anesth 2016; 30:e52-e53. [PMID: 27543994 DOI: 10.1053/j.jvca.2016.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Indexed: 11/11/2022]
Affiliation(s)
- Jan Boublik
- New York University Langone Medical Center, Hospital for Joint Diseases, New York, NY
| | - Stephen C Haskins
- Hospital for Special Surgery and, Weill Cornell College of Medicine, New York, NY
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Kirksey MA, Haskins SC, Cheng J, Liu SS. Local Anesthetic Peripheral Nerve Block Adjuvants for Prolongation of Analgesia: A Systematic Qualitative Review. PLoS One 2015; 10:e0137312. [PMID: 26355598 PMCID: PMC4565585 DOI: 10.1371/journal.pone.0137312] [Citation(s) in RCA: 138] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 08/14/2015] [Indexed: 12/13/2022] Open
Abstract
Background The use of peripheral nerve blocks for anesthesia and postoperative analgesia has increased significantly in recent years. Adjuvants are frequently added to local anesthetics to prolong analgesia following peripheral nerve blockade. Numerous randomized controlled trials and meta-analyses have examined the pros and cons of the use of various individual adjuvants. Objectives To systematically review adjuvant-related randomized controlled trials and meta-analyses and provide clinical recommendations for the use of adjuvants in peripheral nerve blocks. Methods Randomized controlled trials and meta-analyses that were published between 1990 and 2014 were included in the initial bibliographic search, which was conducted using Medline/PubMed, Cochrane Central Register of Controlled Trials, and EMBASE. Only studies that were published in English and listed block analgesic duration as an outcome were included. Trials that had already been published in the identified meta-analyses and included adjuvants not in widespread use and published without an Investigational New Drug application or equivalent status were excluded. Results Sixty one novel clinical trials and meta-analyses were identified and included in this review. The clinical trials reported analgesic duration data for the following adjuvants: buprenorphine (6), morphine (6), fentanyl (10), epinephrine (3), clonidine (7), dexmedetomidine (7), dexamethasone (7), tramadol (8), and magnesium (4). Studies of perineural buprenorphine, clonidine, dexamethasone, dexmedetomidine, and magnesium most consistently demonstrated prolongation of peripheral nerve blocks. Conclusions Buprenorphine, clonidine, dexamethasone, magnesium, and dexmedetomidine are promising agents for use in prolongation of local anesthetic peripheral nerve blocks, and further studies of safety and efficacy are merited. However, caution is recommended with use of any perineural adjuvant, as none have Food and Drug Administration approval, and concerns for side effects and potential toxicity persist.
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Affiliation(s)
- Meghan A Kirksey
- Department of Anesthesiology, Hospital for Special Surgery, New York, New York, United States of America; Department of Anesthesiology, Weill College of Medicine at Cornell University, New York, New York, United States of America
| | - Stephen C Haskins
- Department of Anesthesiology, Hospital for Special Surgery, New York, New York, United States of America; Department of Anesthesiology, Weill College of Medicine at Cornell University, New York, New York, United States of America
| | - Jennifer Cheng
- Department of Anesthesiology, Hospital for Special Surgery, New York, New York, United States of America
| | - Spencer S Liu
- Department of Anesthesiology, Hospital for Special Surgery, New York, New York, United States of America; Department of Anesthesiology, Weill College of Medicine at Cornell University, New York, New York, United States of America
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Affiliation(s)
- RA Webster
- Animal Emergency Service; 104 Eastlake St; Carrara; Queensland; 4211; Australia
| | - JT Mackie
- Gribbles Veterinary Pathology; Eight Mile Plains; Queensland; Australia
| | - SC Haskins
- Department of Surgical and Radiological Sciences; School of Veterinary Medicine; University of California; Davis; CA; USA
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Hopper K, Haskins SC, Rezende M. INDICATIONS, MANAGEMENT AND OUTCOME OF LONG TERM POSITIVE PRESSURE VENTILATION IN DOGS AND CATS: 152 CASES (1991-2001). J Vet Emerg Crit Care (San Antonio) 2004. [DOI: 10.1111/j.1476-4431.2004.t01-29-04035.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Scott NE, Haskins SC, Aldrich J. ANALYZER-CALCULATED OXYHEMOGLOBIN SATURATION AND OXYGEN CONTENT VALUES ARE COMPARABLE TO HAND-CALCULATED VALUES USING A NORMAL CANINE OXYHEMOGLOBIN DISSOCIATION RELATIONSHIP IN UNSEDATED HEALTHY DOGS. J Vet Emerg Crit Care (San Antonio) 2004. [DOI: 10.1111/j.1476-4431.2004.t01-12-04035.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Patients that require positive pressure ventilation to maintain sufficient alveolar ventilation or pulmonary gas exchange may eventually reach a point in the course of their care wherein mechanical ventilation is no longer necessary. This process of transferring the work of breathing from the ventilator back to the patient is referred to as ventilator weaning. The term "ventilator weaning" may be used to refer to all methods by which this transfer of workload may be accomplished. In many patients, particularly those with short-lasting or readily correctable causes of respiratory insufficiency (e.g., general anesthesia), the discontinuation of positive pressure ventilation may be easily achieved. Indeed, in patients awakening from general anesthesia, the axiom "awake enough to blink, awake enough to breath" may prove to be a sufficient guideline. However, in those patients requiring long-term mechanical ventilatory support, the process can prove to be both frustrating and exceptionally challenging. It is of crucial importance to identify those patients that may be successfully weaned because of both the financial impact of prolonged intensive care unit hospitalization and the risks imposed on the patient by the process of positive pressure ventilation. To be able to predict which patients may be ready to be weaned from the ventilator requires an understanding of the balance between the work of breathing (ventilatory load) and the ability of the patient's respiratory pump to meet those needs (ventilatory capacity). The management of patients experiencing difficulty during the weaning process requires that the clinician recognize imbalances between ventilatory load and capacity and to correct these imbalances once identified.
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Affiliation(s)
- M S Mellema
- Veterinary Medical Teaching Hospital, Davis, CA, USA
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Abstract
Pulmonary hypertension may result from an increase in vascular resistance caused by persistent hypoxia. We have investigated the effects of adenosine triphosphate (ATP), administered into the pulmonary artery, on haemodynamic changes occurring in anaesthetized adult dogs subjected to acute hypoxic pulmonary vasoconstriction. Hypoxia alone (ventilation with 10% O2/90% N2) caused significant increases in mean pulmonary arterial blood pressure (PAP), central venous pressure (CVP), and cardiac index (CI) by 71, 102 and 38%, respectively. ATP (0.03-3.0 micromol/kg/min approximately 0.02-1.65 mg/kg/min), when infused under hypoxic conditions, significantly reduced both mean PAP and systemic arterial blood pressure (ABP) in a dose-dependent manner. The maximum decrease in mean PAP amounted to 20%; mean ABP, on the other hand, was decreased by up to 52% (P<0.01). Heart rate, CI, CVP and pulmonary occlusion pressure were not dose-dependently affected by ATP. Our data indicate that while pulmonary arterial administration of ATP in mature dogs during hypoxic pulmonary hypertension causes dilation in the pulmonary vascular bed, it is even more effective in dilating the systemic vasculature. This result suggests a need for further evaluation and warrants cautious use of ATP in the treatment of hypoxic pulmonary hypertension in adult dogs.
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Affiliation(s)
- B Driessen
- Veterinary Medical Teaching Hospital, University of California, Davis 95616, USA.
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Gronert GA, Fung DL, Haskins SC, Steffey EP. Deep sedation and mechanical ventilation without paralysis for 3 weeks in normal beagles: exaggerated resistance to metocurine in gastrocnemius muscle. Anesthesiology 1999; 90:1741-5. [PMID: 10360874 DOI: 10.1097/00000542-199906000-00032] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients in the intensive care unit may have muscle weakness in the recovery phase, and disuse atrophy may play a role in this weakness. To assess this problem, the authors measured changes in the potency of the nondepolarizing neuromuscular blocking agent metocurine in a canine model that involved 3 weeks of intensive care, nonparalyzing anesthesia with pentobarbital, and positive-pressure ventilation. METHODS Six dogs were anesthetized with pentobarbital to a sufficient depth that spontaneous and reflex muscle movements were absent. Their tracheas were intubated, their lungs were mechanically ventilated, and they received round-the-clock intensive medical and nursing care for 3 weeks. Transduced gastrocnemius muscle responses to metocurine were determined weekly. A 4- to 15-min infusion of 148-4,300 microg/min (longer durations and greater concentrations on progressive weeks) yielded more than 80% paralysis. Serial metocurine plasma concentrations during the onset of the block and recovery provided data to determine pharmacokinetics using NONMEM. Metocurine plasma concentrations and the degree of paralysis were used to model the effect compartment equilibration constant, and the Hill equation was used to yield the slope factor and potency within the effect compartment. RESULTS The metocurine effect compartment concentration associated with a 50% diminution of twitch height after 3 weeks was 1,716+/-1,208 ng/ml (mean +/- SD), which was significantly different from 257+/-34 ng/ml, the value on day 0. There were no pharmacokinetic differences. CONCLUSION The absence of muscle tone and reflex responsiveness for 3 weeks was associated with exaggerated resistance to the neuromuscular blocker metocurine.
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Affiliation(s)
- G A Gronert
- Department of Anesthesiology, School of Medicine, University of California, Davis 95616, USA.
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Gronert GA, Haskins SC, Steffey EP, Fung D. Plasma electrolyte and metabolite concentrations associated with pentobarbital or pentobarbital-propofol anesthesia during three weeks' mechanical ventilation and intensive care in dogs. Lab Anim Sci 1998; 48:513-9. [PMID: 10090067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Propofol and pentobarbital were used for deep sedation during prolonged mechanical ventilation (3 weeks) and nutritional supplementation in 17 clinically normal dogs in an intensive care setting. Tolerance developed to both drugs. Propofol, in combination with pentobarbital, at an infusion rate of 75 micrograms/kg of body weight per minute was preferred. Pentobarbital infusion alone, begun at the rate of 5 to 6 mg.kg-1.h-1, was satisfactory. The combination of both drugs provided smooth, stable anesthesia and required minimal interventions by intensive care unit personnel. Blood gas tensions and electrolyte, parathyroid hormone (PTH), and metabolite concentrations were generally stable throughout, unless condition of the dog deteriorated (e.g., infection, pneumothorax). Hematocrit and red blood cell count decreased with time, likely attributable principally to multiple blood sample collections. White blood cell count, alkaline phosphatase, phosphate, fibrinogen, cholesterol, and triglyceride values increased with time, in association with pentobarbital and the combination of pentobarbital and propofol. Some of these changes appear to have been related to generic responses to stress and inflammation, some to altered metabolism, and some to the lipid solvent of propofol. The increase in triglyceride concentration was greater when propofol was used. Mortality was 47%, with death occurring between days 2 and 18.
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Affiliation(s)
- G A Gronert
- Department of Anesthesiology, School of Medicine, University of California, Davis 95616, USA
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Abstract
Stewart used physicochemical principles of aqueous solutions to develop an understanding of variables that control hydrogen ion concentration (H+) in body fluids. He proposed that H+ concentration in body fluids was determined by PCO2, strong ion difference (SID = sum of strong positive ion concentrations minus the sum of the strong anion concentrations) and the total concentration of nonvolatile weak acid (Atot) under normal circumstances. Albumin is the major weak acid in plasma and represents the majority of Atot. These 3 variables were defined as independent variables, which determined the values of all other relevant variables (dependent) in plasma, including H+. The major strong ions in plasma are sodium and chloride. The difference between Na+ and Cl- may be used as an estimation of SID. A decrease in SID below normal results in acidosis (increase in H+) and an increase in SID above normal results in alkalosis (decrease in H+). Unidentified strong anions such as lactate will decrease the SID, if present. Equations developed by Fencl allow Stewart's work to be easily applied clinically for evaluating the metabolic (nonrespiratory) contribution to acid-base balance. This approach separates the net metabolic abnormality into components, and allows one to easily detect mixed metabolic acid-base abnormalities. The Fencl approach provides insight into the nature and severity of the disturbances that exist in the patient. Sodium, chloride, protein, and unidentified anion derangements may contribute to the observed metabolic acid-base imbalance.
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Affiliation(s)
- K J Whitehair
- Veterinary Medical Teaching Hospital, School of Veterinary Medicine, University of California, Davis 95616
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Ilkiw JE, Pascoe PJ, Haskins SC, Patz JD, Jaffe R. The cardiovascular sparing effect of fentanyl and atropine, administered to enflurane anesthetized dogs. Can J Vet Res 1994; 58:248-53. [PMID: 7889455 PMCID: PMC1263707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Cardiovascular effects of high dose opioid together with low dose inhalant were compared with inhalant alone to determine whether opioid/inhalant techniques were less depressant on the cardiovascular system. The effects of positive pressure ventilation and increasing heart rate to a more physiological level were also studied. Cardiovascular measurements recorded during administration of enflurane at 1.3 minimum alveolar concentration (MAC; 2.89 +/- 0.02%) to spontaneously breathing dogs (time 1) and during controlled ventilation [arterial carbon dioxide tension at 40 +/- 3 mmHg (time 2)] were similar. At time 2, mixed venous oxygen tension and arterial and mixed venous carbon dioxide tensions were significantly decreased, while arterial and mixed venous pH were significantly increased compared to measurements at time 1. After administration of fentanyl to achieve plasma fentanyl concentration of 71.7 +/- 14.4 ng/mL and reduction of enflurane concentration to yield 1.3 MAC multiple (0.99 +/- 0.01%), heart rate significantly decreased, while mean arterial pressure, central venous pressure, stroke index, and systemic vascular resistance index increased compared to measurements taken at times 1 and 2. Pulmonary arterial occlusion pressure was significantly increased compared to measurements taken at time 2. After administration of atropine until heart rate was 93 +/- 5 beats/min (plasma fentanyl concentration 64.5 +/- 13.5 ng/mL) heart rate, mean arterial pressure, cardiac index, oxygen delivery index, and venous admixture increased significantly compared to values obtained at all other times.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- J E Ilkiw
- Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis 95616
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Pascoe PJ, Haskins SC, Ilkiw JE, Patz JD. Cardiopulmonary effects of halothane in hypovolemic dogs. Am J Vet Res 1994; 55:121-6. [PMID: 8141484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Cardiopulmonary effects of halothane administration were studied in hypovolemic dogs. Baseline cardiopulmonary data were recorded from conscious dogs after instrumentation. Hypovolemia was induced by withdrawal of blood from dogs until mean arterial pressure of 60 mm of Hg was achieved. Blood pressure was maintained at 60 mm of Hg for 1 hour, by further removal or replacement of blood. Halothane was delivered by face mask, dogs were intubated, then halothane end-tidal concentration of 1.13 +/- 0.02% was maintained, and cardiopulmonary effects were measured 3, 15, 30, and 60 minutes later. After blood withdrawal and prior to halothane administration, systemic vascular resistance index, oxygen extraction, and base deficit increased. Compared with baseline values, these variables were decreased: mean arterial pressure, mean pulmonary arterial pressure, pulmonary arterial occlusion pressure, cardiac index, oxygen delivery index, oxygen consumption index, mixed venous oxygen tension, mixed venous oxygen content, venous admixture, arterial bicarbonate concentration, and mixed venous pH. At all times after intubation, arterial and venous oxygen tensions and mixed venous carbon dioxide tensions were increased. Three minutes after intubation, base deficit and mixed venous carbon dioxide tension increased, and mean arterial pressure and arterial and venous pH decreased, compared with values measured immediately prior to halothane administration. Fifteen minutes after intubation, systemic vascular resistance index decreased and, at 15 and 30 minutes, mean arterial pressure and arterial and venous pH remained decreased. At 60 minutes, mean pulmonary arterial pressure and pulmonary arterial occlusion pressure were increased and mixed venous pH was decreased, compared with values measured before halothane administration.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- P J Pascoe
- Department of Surgery, School of Veterinary Medicine, University of California, Davis 95616-8745
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Ilkiw JE, Pascoe PJ, Haskins SC, Patz JD. Cardiovascular and respiratory effects of propofol administration in hypovolemic dogs. Am J Vet Res 1992; 53:2323-7. [PMID: 1476316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Cardiopulmonary effects of propofol were studied in hypovolemic dogs from completion of, until 1 hour after administration. Hypovolemia was induced by withdrawal of blood from dogs until mean arterial pressure of 60 mm of Hg was achieved. After stabilization at this pressure for 1 hour, 6 mg of propofol/kg of body weight was administered IV to 7 dogs, and cardiopulmonary effects were measured. After blood withdrawal and prior to propofol administration, oxygen utilization ratio increased, whereas mean arterial pressure, mean pulmonary arterial pressure, central venous pressure, pulmonary capillary wedge pressure, cardiac index, oxygen delivery, mixed venous oxygen tension, and mixed venous oxygen content decreased from baseline. Three minutes after propofol administration, mean pulmonary arterial pressure, pulmonary vascular resistance, oxygen utilization ratio, venous admixture, and arterial and mixed venous carbon dioxide tensions increased, whereas mean arterial pressure, arterial oxygen tension, mixed venous oxygen content, arterial and mixed venous pH decreased from values measured prior to propofol administration. Fifteen minutes after propofol administration, mixed venous carbon dioxide tension was still increased; however by 30 minutes after propofol administration, all measurements had returned to values similar to those measured prior to propofol administration.
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Affiliation(s)
- J E Ilkiw
- Department of Surgery, School of Veterinary Medicine, University of California, Davis 95616
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Pascoe PJ, Ilkiw JE, Haskins SC, Patz JD. Cardiopulmonary effects of etomidate in hypovolemic dogs. Am J Vet Res 1992; 53:2178-82. [PMID: 1466517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Cardiopulmonary effects of etomidate administration were studied in hypovolemic dogs. Baseline cardiopulmonary data were recorded from conscious dogs after instrumentation. Hypovolemia was induced by withdrawal of blood from dogs until mean arterial pressure of 60 mm of Hg was achieved. Blood pressure was maintained at 60 mm of Hg for 1 hour, by further removal or replacement of blood. One milligram of etomidate/kg of body weight was then administered IV to 7 dogs, and the cardiopulmonary effects were measured 3, 15, 30, and 60 minutes later. After blood withdrawal and prior to etomidate administration, heart rate, arterial oxygen tension, and oxygen utilization ratio increased. Compared with baseline values, the following variables were decreased: mean arterial pressure, mean pulmonary arterial pressure, central venous pressure, pulmonary wedge pressure, cardiac index, oxygen delivery, mixed venous oxygen tension, mixed venous oxygen content, and arterial carbon dioxide tension. Three minutes after etomidate administration, central venous pressure, mixed venous and arterial carbon dioxide tension, and venous admixture increased, and heart rate, arterial and venous pH, and arterial oxygen tension decreased, compared with values measured immediately prior to etomidate administration. Fifteen minutes after etomidate injection, arterial pH and heart rate remained decreased. At 30 minutes, only heart rate was decreased, and at 60 minutes, mean arterial pressure was increased, compared with values measured before etomidate administration. Results of this study indicate that etomidate induces minimal changes in cardiopulmonary function when administered to hypovolemic dogs.
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Affiliation(s)
- P J Pascoe
- Department of Surgery, School of Veterinary Medicine, University of California, Davis 95616-8745
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Abstract
Oxymorphone was administered intravenously (IV) to 10 dogs (0.4 mg/kg initial dose followed by 0.2 mg/kg three times at 20-minute intervals). Four hours after the last dose of oxymorphone, heart rates were less than 60 bpm in six dogs. After atropine (0.01 mg/kg IV) was administered, heart rate decreased in five dogs and sinus arrhythmia or second degree heart block occurred in four of them. A second injection of atropine (0.01 mg/kg IV) was administered 5 minutes after the first and the heart rates increased to more than 100 bpm in all six dogs. Ten minutes after the second dose of atropine, heart rate, cardiac output, left ventricular minute work, venous admixture, and oxygen transport were significantly increased, whereas stroke volume, central venous pressure, systemic vascular resistance, and oxygen extraction ratio were significantly decreased from pre-atropine values. The PaCO2 increased and the PaO2 decreased but not significantly. The oxymorphone-induced bradycardia did not produce any overtly detrimental effects in these healthy dogs. Atropine reversed the bradycardia and improved measured cardiovascular parameters.
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Affiliation(s)
- V S Copland
- Department of Surgery, School of Veterinary Medicine, University of California, Davis 95616
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Concannon KT, Haskins SC, Feldman BF. Hemostatic defects associated with two infusion rates of dextran 70 in dogs. Am J Vet Res 1992; 53:1369-75. [PMID: 1380787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
We investigated changes in hemostatic function after infusion of 6% dextran 70 (high molecular weight dextran) at 2 rates. Six healthy dogs underwent 3 regimens: 20 ml of dextran/kg of body weight administered in 1 hour (trial A), 20 ml of dextran/kg administered in 30 minutes (trial B), and 0.9% sodium chloride solution as a control administered over 1 hour to achieve hemodilution equivalent to that for 20 ml of dextran/kg (trial C). Before and at 2, 4, 8, and 24 hours after the start of trials A and B, we measured PCV, total solids (TS) concentration, amount of von Willebrand factor antigen (vWf:Ag), factor VIII coagulant activity (VIII:C), prothrombin time, activated partial thromboplastin time (APTT), platelet retention in a glass bead column, and buccal mucosa bleeding time (BMBT). Values were not obtained at 8 and 24 hours for trial C. Saline-induced changes in hemostasis were significant (P less than 0.05) from baseline throughout the sample collection period. Significant differences (P less than 0.05) between trial A and control were observed for vWf:Ag, VIII:C, BMBT, APTT, TS, and PCV values at 2 hours, and for VIII:C at 4 hours. Significant differences (P less than 0.05) between trial B and control were observed for APTT, TS, and PCV values at 2 hours, and for vWf:Ag, VIII:C, BMBT, APTT, TS, and PCV values at 4 hours. During trials A and B, mean values of analytes infrequently deviated from reference intervals, and clinical signs of bleeding were not observed in any dog.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- K T Concannon
- Veterinary Medical Teaching Hospital, School of Veterinary Medicine, University of California, Davis 95616
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Haskins SC. Management of septic shock. J Am Vet Med Assoc 1992; 200:1915-24. [PMID: 1639696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- S C Haskins
- Department of Surgery, School of Veterinary Medicine, University of California, Davis 95616-8745
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Haskins SC. Internal cardiac compression. J Am Vet Med Assoc 1992; 200:1945-6. [PMID: 1639700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- S C Haskins
- Department of Surgery, School of Veterinary Medicine, University of California, Davis 95616-8745
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Affiliation(s)
- S C Haskins
- Department of Surgery, University of California, School of Veterinary Medicine, Davis
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Affiliation(s)
- S C Haskins
- Department of Surgery, University of California, School of Veterinary Medicine, Davis
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Affiliation(s)
- A M Klide
- Department of Clinical Studies-Philadelphia, University of Pennsylvania School of Veterinary Medicine
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Affiliation(s)
- S C Haskins
- Department of Surgery, University of California, School of Veterinary Medicine, Davis
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Affiliation(s)
- S C Haskins
- Department of Surgery, University of California, School of Veterinary Medicine, Davis
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Affiliation(s)
- S C Haskins
- Department of Surgery, University of California, School of Veterinary Medicine, Davis
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Affiliation(s)
- S C Haskins
- Department of Surgery, University of California, Davis, School of Veterinary Medicine
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Haskins SC. Advantages and guidelines for using enflurane. Vet Clin North Am Small Anim Pract 1992; 22:326. [PMID: 1585566 DOI: 10.1016/s0195-5616(92)50624-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- S C Haskins
- Department of Surgery, University of California, School of Veterinary Medicine, Davis
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Affiliation(s)
- S C Haskins
- Department of Surgery, University of California, School of Veterinary Medicine, Davis
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45
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Affiliation(s)
- S C Haskins
- Department of Surgery, University of California, School of Veterinary Medicine, Davis
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46
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Haskins SC. The case for in circuit vaporizers. Vet Clin North Am Small Anim Pract 1992; 22:391-2. [PMID: 1585584 DOI: 10.1016/s0195-5616(92)50646-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
In circuit vaporizers have some characteristics that differ from out of circuit vaporizers. In circuit vaporizers are easy to use, effective, and offer several clinical advantages.
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Affiliation(s)
- S C Haskins
- Department of Veterinary Surgery, University of California, School of Veterinary Medicine, Davis
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47
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Affiliation(s)
- S C Haskins
- Department of Surgery, University of California, School of Veterinary Medicine, Davis
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48
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Affiliation(s)
- S C Haskins
- Department of Surgery, University of California, School of Veterinary Medicine, Davis
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49
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Affiliation(s)
- S C Haskins
- Department of Surgery, University of California, School of Veterinary Medicine, Davis
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50
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Moon PF, Snyder JR, Haskins SC, Perron PR, Kramer GC. Effects of a highly concentrated hypertonic saline-dextran volume expander on cardiopulmonary function in anesthetized normovolemic horses. Am J Vet Res 1991; 52:1611-8. [PMID: 1722655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Conventional fluid resuscitation is unsatisfactory in a small percentage of equine emergency surgical cases because the large volumes of fluids required cannot be given rapidly enough to adequately stabilize the horse. In anesthetized horses, the volume expansion and cardiopulmonary effects of a small volume of highly concentrated hypertonic saline-dextran solution were evaluated as an alternative initial fluid choice. Seven halothane-anesthetized, laterally recumbent, spontaneously ventilating, normovolemic horses were treated with a 25% NaCl-24% dextran 70 solution (HSD) at a dosage of 1.0 ml/kg of body weight, IV, infused over 10 minutes, and the effects were measured for 120 minutes after infusion. Plasma volume expansion was rapid and significant (from 36.6 +/- 4.6 ml/kg to 44.9 +/- 4.8 ml/kg), and remained significantly expanded for the duration of the experiment. Packed cell volume, total blood hemoglobin, and plasma protein concentrations significantly decreased, confirming rapid and sustained volume expansion with hemodilution. Cardiac index and stroke index immediately increased and remained high for the entire study (from 69.6 +/- 15.3 ml/min/kg to 106.6 +/- 28.4 ml/min/kg, and from 1.88 +/- 0.49 ml/beat/kg to 2.50 +/- 0.72 ml/beat/kg, respectively). Systemic vascular resistance significantly decreased immediately after HSD infusion and remained decreased for the duration of the study (from 1.41 +/- 0.45 mm of Hg/ml/min/kg to 0.88 +/- 0.22 mm of Hg/ml/min/kg). Arterial and venous blood oxygen content decreased significantly because of hemodilution, but actual oxygen transport transiently increased at the 10-minute measurement before returning toward baseline.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- P F Moon
- Veterinary Medical Teaching Hospital, Davis, CA 95616
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