A comparison of the accuracy of ulnar versus median nerve stimulation for neuromuscular monitoring

BACKGROUND: Inexperienced anesthesiologists are frequently unclear as to whether to stimulate the ulnar or median nerve to monitor the adductor pollicis. The primary purpose of this study was to determine whether monitoring the adductor pollicis by positioning the stimulating electrodes over the median nerve is an acceptable alternative to applying electrodes over the ulnar nerve.0aMETHODS: In 20 patients anesthetized with propofol and remifentanil, one pair of stimulating electrodes was positioned over the ulnar nerve. A second pair was placed over the median nerve on the other hand. The acceleromyographic response was monitored on both hands. Rocuronium 0.6 mg/kg was administered. Single twitch (ST) and train-of-four (TOF) stimulations were applied alternatively to both sites.0aRESULTS: None of the patients showed a twitch response at either site after injection of rocuronium. There were no differences in the mean supramaximal threshold, mean initial TOF ratio, or mean initial ST ratio between the two sites. Bland-Altman analysis revealed a bias (limit of agreement) in the TOF and ST ratios over the median nerve of 7% (with that of the ulnar nerve value, and the median nerve ST ratio was overestimated by 72.9%, as compared to that of the ulnar nerve.0aCONCLUSIONS: The ulnar and median nerves cannot be used interchangeably for accurate neuromuscular monitoring

Pharmacological agents for preventing morbidity associated with the haemodynamic response to tracheal intubation

Background: Several drugs have been used in attenuating or obliterating the response associated with laryngoscopy and tracheal intubation. These changes are of little concern in relatively healthy patients but can lead to morbidity and mortality in the high risk patient population.Objectives: The primary objective of this review was to determine the effectiveness of pharmacological agents in preventing the morbidity and mortality resulting from the haemodynamic changes in response to laryngoscopy and tracheal intubation in adult patients aged 18 years and above who were undergoing elective surgery in the operating room setting.SEARCH Methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2011, Issue 6), MEDLINE (1950 to June 2011), EMBASE (1980 to June 2011), and the bibliographies of published studies. We reran our search from June 2011 to December 2012 and will deal with these studies when we update the review.SELECTION CRITERIA: We included randomized controlled trials (RCTs) that compared a drug used as an intervention for preventing or attenuating the haemodynamic response to tracheal intubation to a control group, and that mentioned mortality, major morbidity, arrhythmia or electrocardiogram (ECG) evidence of ischaemia in the methodology, results, or discussion section of the reports.DATA COLLECTION AND ANALYSIS: Two authors independently assessed trial quality and extracted the outcome data.MAIN Results: We included 72 RCTs. The included trials studied the effects of 32 drugs belonging to different pharmacological groups. Only two trials mentioned the primary outcome of morbidity and mortality related to the haemodynamic response to tracheal intubation. Of the secondary outcomes, 40 of the included trials observed arrhythmia only, 11 observed myocardial ischaemia only and 20 observed both arrhythmias and myocardial ischaemia. Arrhythmias were observed in 2932 participants and myocardial ischaemia in 1616 participants. Arrhythmias were observed in 134 out of 993 patients in the control group compared to 80 out of 1939 in the intervention group. The risk of arrhythmias was significantly reduced with pharmacological interventions in the pooled data (Peto odds ratio (OR) 0.19, 95% CI 0.14 to 0.26, P \u3c 0.00001, I(2)= 47%). Local anaesthetics, calcium channel blockers, beta blockers and narcotics reduced the risk of arrhythmia in the intervention group compared to the control group. Myocardial ischaemia was observed in 21 out of 604 patients in the control group compared to 10 out of 1012 in the treatment group; the result was statistically significant (Peto OR 0.45, 95% CI 0.22 to 0.92, P = 0.03, I(2) = 19%). However, in subgroup analysis only local anaesthetics significantly reduced the ECG changes indicating ischaemia, but this evidence came from one study. The majority of the studies had a negative outcome. Hypotension and bradycardia were reported with 40 g kg(-1) intravenous alfentanil, chest rigidity with 75 ug kg(-1) alfentanil, and increased bronchomotor tone with sympathetic blockers.There were 17 studies which included high risk patients. Pharmacological treatment in this group resulted in the reduction of arrhythmias when the data from nine trials looking at arrhythmias were pooled (Peto OR 0.18, 95% CI 0.05 to 0.59, P = 0.005, I(2) = 80%). The analysis from four studies was not included. Three of these trials looked at the effect of sympathetic blockers but arrhythmias or myocardial ischaemia was observed throughout the perioperative period in two studies and some patients had arrhythmias due to atropine premedication in the third study. In the fourth study the authors mentioned myocardial ischaemia in the objectives section but did not report it in the results.AUTHORS\u27 CONCLUSIONS: The risk of arrhythmias associated with tracheal intubation was significantly reduced with pre-induction administration of local anaesthetics, calcium channel blockers, beta blockers and narcotics compared to placebo. Pharmacological intervention also reduced the risk of ECG evidence of myocardial ischaemia in the pooled data. Lignocaine pretreatment showed a significant effect but evidence came from one study only. The data suggested that there may be a reduction in ECG evidence of myocardial ischaemia with beta blocker pretreatment but this difference was not statistically significant. There is a need to focus on outcomes rather than haemodynamic measurements alone when studying this response in future trials

The effects of intravenous lidocaine before propofol induction in premedicated dogs

OBJECTIVE: The effects of lidocaine, administered before induction of anaesthesia with propofol, on arterial blood pressure, heart rate, respiratory rate, cough reflex, ease of intubation, extrapyramidal signs and required dose of propofol in healthy premedicated dogs were evaluated. METHODS: Twenty-four client-owned dogs were premedicated intramuscularly with 1 mu g/kg dexmedetomidine and 0 center dot 2 mg/kg methadone, and randomly allocated to receive 2 mg/kg lidocaine (group L) or saline (group P) 120 seconds before induction of anaesthesia with propofol. Heart rate, non-invasive arterial blood pressure and respiratory rate were assessed at pre-established intervals. Quality of intubation, cough reflex and the occurrence of adverse effects were scored according to predefined scales. The total amount of propofol administered was also recorded. RESULTS: Cardiovascular and respiratory variables changed over time but were not significantly different between treatments. No significant differences between groups were found for the incidence of coughing, quality of intubation, adverse effects and propofol intubation dose. CLINICAL SIGNIFICANCE: Intravenous administration of lidocaine 2 mg/kg before propofol induction was not associated with significant cardiovascular and respiratory benefits compared to standard induction and did not result in a propofol dose-sparing effect or improvement of the quality of intubation in dogs premedicated with dexmedetomidine and methadone