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Mortality associated with hip fracture is high in elderly patients. Surgical repair within 24 hr after admission is recommended by The Royal College of Physicians' guidelines; however, the effect of operative delay on mortality remains controversial. The objective of this study was to determine whether operative delay increases mortality in elderly patients with hip fracture.Published English-language reports examining the effect of surgical delay on mortality in patients who underwent hip surgery were identified from electronic databases. The primary outcome was defined as all-cause mortality at 30 days and at one year. Effect sizes with corresponding 95% confidence intervals were calculated by using a DerSimonian-Laird randomeffects model.Sixteen prospective or retrospective observational studies (257,367 patients) on surgical timing and mortality in hip fracture patients were selected. When a cut-off of 48 hr from the time of admission was used to define operative delay, the odds ratio for 30-day mortality was 1.41 (95% CI = 1.29-1.54, P0.001), and that for one-year mortality was 1.32 (95% CI = 1.21-1.43, P0.001).In hip fracture patients, operative delay beyond 48 hr after admission may increase the odds of 30-day all-cause mortality by 41% and of one-year all-cause mortality by 32%. Potential residual confounding factors in observational studies may limit definitive conclusions. Although routine surgery within 48 hr after admission is hard to achieve in most facilities, anesthesiologists must be aware that an undue delay may be harmful to hip fracture patients, especially those at relatively low risk or those who are young.

Objective: Off-pump coronary artery bypass (OPCAB) surgery has become a widely accepted alternative to standard coronary artery bypass graft (CABG) surgery using cardiopulmonary bypass; however, the influence of intraoperative conversion from OPCAB to standard CABG on costs and quality of life is unclear. The objective of this study was to determine whether intraoperative conversion affects costs and quality of life. Design: A decision-analysis model and Monte Carlo simulation. Setting: The US healthcare system over a maximum 10-year lifetime horizon. Participants: A hypothetical cohort of 60-year-old male patients undergoing elective OPCAB surgery or standard CABG surgery. Interventions: Each patient was entered into the decision tree with varying transition probabilities. Outcome measures included quality-adjusted life-years (QALYs) and costs in US dollars. Measurements and Main Results: In base-case analysis, OPCAB surgery led to a discounted lifetime cost of $91,282 and 7.64 discounted QALYs, and standard CABG surgery led to $91,685 and 7.52 QALYs. Patients who required conversion from off-pump to on-pump surgery incurred a cost of $103,909 and gained 6.63 QALYs. OPCAB is dominant (less costly and more effective) if the conversion rate is below 8.5%, whereas costs increase exponentially if the probability of conversion exceeds 15%. Sixty-one percent of the Monte Carlo simulations favored cost-effectiveness of the OPCAB strategy. Conclusion: In low-risk patients, OPCAB surgery, in comparison to standard CABG surgery, would increase QALYs by reducing complications related to cardiopulmonary bypass, but it would result in lifetime costs similar to those of standard CABG surgery. The benefit of OPCAB may be offset by the risk of intraoperative conversion.

Background and Objectives: It is suggested that the potency of 1% ropivacaine is comparable to that of 0.75% bupivacaine and higher than that of 2% lidocaine. Alkalinized lidocaine reportedly enhances the block of sacral segments during lumbar epidural anesthesia. We hypothesized that 1% ropivacaine might also block at the lumbosacral segments adequately during lumbar epidural anesthesia. Methods: Forty-two patients undergoing lumbar epidural anesthesia at L4-5 or L5-S1 were randomly divided into 3 groups and received either 14 mL 2% lidocaine (lidocaine group), 2% lidocaine with epinephrine 1:200,000 and bicarbonate (lidocaine-epinephrine-bicarbonate group), or 1% ropivacaine (ropivacaine group). Pain threshold after repeated electrical stimulation was used to assess sensory block at the L2, S1, and S3 segments while motor block was evaluated using the modified Bromage Scale. Results: Demographic data were comparable between the groups. Significant differences in the pH of each local anesthetic solution were found between the 3 groups. Pain thresholds at the S1 and S3 segments in the lidocaine-epinephrine-bicarbonate group were significantly higher and sensory block onset faster than in the other groups. However, no significant differences were found in either the pain threshold or the onset of sensory block of the L2 segment between the groups. No significant differences in the pain threshold, onset of sensory block, or Bromage Scale were found between the lidocaine and ropivacaine groups. Conclusions: We conclude that 1% ropivacaine does not improve block of sacral segments within 20 minutes following epidural ropivacaine administration. Reg Anesth Pain Med 2003;28:208-214.

It has been reported that the addition of epinephrine and/or bicarbonate to local anesthetic enhances the depth of epidural blockade and that initial partial bolus injection results in greater caudal spread. We evaluated the anesthetic effects of lidocaine with epinephrine and/or bicarbonate injected into the epidural space by bolus or catheter injection.Forty-four patients undergoing epidural anesthesia with 17 mL of 2% lidocaine containing 1:200,000 epinephrine at L4-5 or L5-S1 were randomly divided into four groups. Lidocaine was administrated via epidural catheter [lidocaine catheter (LC) group] or Tuohy needle (lidocaine bolus group), lidocaine-bicarbonate was administrated via catheter (lidocaine-bicarbonate catheter group) or needle [lidocaine-bicarbonate bolus (LBB) group]. Pain threshold after repeated electrical stimulation was performed at L2 and S1 regions. Motor blockade was evaluated using the Bromage scale. Sympathetic blockade was assessed with plethysmographic waveforms from the toe.The pain threshold of the S1 dermatome in LBB group was significantly higher than in the lidocaine only groups, however, differences in the pain threshold at the L2 dermatome among the groups were insignificant. The onset of sensory blockade in the S1 dermatome in the LBB group was significantly shorter than in the LC group. Significantly greater motor blockade was achieved in the lidocaine-bicarbonate groups than in the lidocaine-only groups. The amplitude of plethysmographic waveforms significantly increased within each group.Epidural bolus injection of lidocaine-bicarbonate with epinephrine improves the pain threshold and speeds the onset of the blockade of the first sacral region.

ラリンゲルマスク(LM)を介してファイバースコープ誘導下に挿管する2方法について検討した。6.5mmカフ付き気管内チューブを留置したLMを挿入し,ファイバースコープ誘導下に気管内挿管したチューブ法(n=28)と,LM挿入後ファイバースコープ誘導下に自作のガイドチューブを挿管し,ガイドチューブ内にgum-elastic bougie(ブジー)を挿入し,LMとガイドチューブを抜去,至適サイズの気管内チューブをブジーを介して挿管したガイド法(n=22)の2方法を比較した。挿管成功率は,チューブ法79%,ガイド法77%であり,2群間に有意差はなかった。挿管時間(LM挿入開始から挿管終了まで)はチューブ法236±106秒(mean±SD),ガイド法463±219秒であり,チューブ法はガイド法に比べ有意に短時間であった。挿管失敗理由はチューブ法ではLM位置不良,ファイバースコープ操作未熟,チューブ気管内挿入不可であった。ガイド法ではファイバースコープ操作未熟,手順不良であった。チューブ法は手順が簡便であり,挿管時間も短いが,挿管チューブの太さが制限される,LMが口腔内に残る,チューブが喉頭蓋などにあたって挿管できないなどの欠点があった。ガイド法ではこの欠点は克服され,麻酔管理上は安全性,確実性が高まったが,手順が煩雑で挿管に時間を要した。ガイド法に慣れるためには日常のトレーニングが必要であると思われた。

Gum-elastic bougie(ブジー)を介して声門部を直視せずに挿管する方法を試み,通常の気管内挿管法と比較検討した.気管内挿管の予定された314例に対し,98例にブジーを介した挿管が(ブジー法),216例に通常挿管(通常法)が行なわれた.挿管成功率は,ブジー法85%,通常法84%であり,初回成功率は,おのおの72%,74%であった(有意差なし).挿管時間は,ブジー法60±55秒(mean±SD),通常法41±54秒であり,初回挿管時間は,おのおの41±15秒,25±15秒であった(有意差あり,P

Acetaminophen (APAP) is a popular analgesic. In the present study, we characterized the pharmacokinetics and pharmacodynamics of APAP in the Japanese. Five healthy volunteers were administered 1000 mg of APAP orally. Five patients with chronic pain were administered the optimal oral dose of APAP ranging from 600 to 1000 mg to allow for an adequate analgesic effect. Plasma APAP and APAP metabolite concentrations were measured in the volunteers, plasma APAP concentrations and pain scores using a visual analog scale were measured in the patients with chronic pain. Patient data were fitted to a first-order absorption one-compartment model with delayed effects accounted for by an effect compartment. A sigmoid Emax model was used as the pharmacodynamic model. Acetaminophen-cysteine metabolites, which are conjugates of the toxic metabolite N-acetyl-p-benzoquinone-imine, were detected in the plasma at levels lower than 0.2 microg/ml, but no side effects were observed. The pharmacokinetic and pharmacodynamic parameter (mean+/-S.D.) estimates were as follows: clearance, 18.7+/-4.7 l/h; distribution volume, 30.9+/-6.8 l; absorption rate constant, 2.4+/-1.3 h(-1); rate constant for the elimination of APAP from the effect compartment, 1.3+/-0.5 h(-1); maximum pain relief score, 4.6+/-2.2 units; effect compartment concentration at 50% maximum, 2.0+/-1.2 microg/ml; and sigmoid factor, 1.3+/-0.7. These results suggest that these parameters can be used to determine an effective APAP dosage regimen for Japanese patients with chronic pain.

Wilson病患者13例の麻酔管理を経験した.年齢は3歳から30歳で,麻酔時間は90分から165分であった.麻酔はチオペンタール導入・亜酸化窒素-酸素-セボフルラン(GOS)維持が6例,チオペンタール導入・亜酸化窒素-酸素-イソフルラン(GOI)維持が4例,GOS導入維持が2例,GOS導入・GOI維持が1例であった.筋弛緩薬は全例ベクロニウムが使用された.術後に肝機能が悪化した症例はなかった.Wilson病患者の麻酔管理上,イソフルランならびにセボフルラン麻酔は特に肝機能面を中心として問題はなかった.

To the Editor: Epidural anesthesia occasionally fails to provide adequate surgical analgesia. Evaluation of the effectiveness of epidural anesthesia is required at an early stage following the administration of local anesthetics. The increase in pulse amplitude from the toe has been utilized as an index of the degree of sympathetic block and may aid in the early detection of successful epidural block.1 Single electric stimulation provides a more reliable predictor of the adequacy of sensory block.2 We assessed the clinical efficacy (sensory block, motor block and sympathetic block) during the early stages of epidural block. Eleven patients undergoing epidural block with 14 mL 2% lidocaine with 1:200000 epinephrine at L4–5 or L5–S1 were studied. Pain threshold after single electric stimulation was performed at L2 and S1. Motor block was evaluated by the Bromage scale. Sympathetic blockade was assessed by plethysmographic waveforms from the toe. Patients were divided into two groups based upon whether the pain threshold did (group A) or did not (group B) reach 60 mA within 20 min. Demographic data was comparable between groups. The threshold significantly increased after ten minutes compared with zero minutes in each group (P

The cardiovascular changes after intubation and at the time of incision under nitrous oxide-oxygen anesthesia with epidural buprenorphine (Bn) were examined. The subjects were 56 patients who underwent abdominal surgery. The patients were divided into two groups in terms of the epidural drugs used, i.e., group I (Bn 0.2 mg + saline 9 ml, n = 31) and group II (Bn 0.2 mg + 1% lidocaine 10 ml, n = 25). The systolic pressure increased significantly (P less than 0.05) to 169 +/- 29 mmHg (mean +/- SD) after intubation and to 162 +/- 28 mmHg after incision in group I, with no decrease in blood pressure during the non-stimulation period. In group II, although there was a significant decrease in blood pressure to 114 +/- 24 mmHg just before incision (P less than 0.05), no elevation of blood pressure was noted after intubation or incision. There was no significant difference between groups I and II with regard to the heart rate and respiratory rate. We were unable to block the cardiovascular reaction after intubation and incision under nitrous oxide-oxygen anesthesia with epidural Bn, requiring local anesthetics or volatile anesthetics. This method, however, is useful for patients in whom a fall of blood pressure should be avoided, e.g., for those with hypovolemia.