Differences in safety climate among hospital anesthesia departments and the effect of a realistic simulation-based training program.

Background: Safety climate is often measured via surveys to identify appropriate patient safety interventions. The introduction of an insurance premium incentive for simulation-based anesthesia crisis resource management (CRM) training motivated our naturalistic experiment to compare the safety climates of several departments and to assess the impact of the training.

Methods: We administered a 59-item survey to anesthesia providers in six academic anesthesia programs (Phase 1).

Droperidol: should the black box be light gray?

In December 2001, the United States Food and Drug Administration (FDA) added a "black box" warning to the labeling for droperidol stating that all doses, even those typically used for postoperative nausea and vomiting, were potentially associated with malignant ventricular dysrhythmias, including torsade de pointes. The 19 cases in which droperidol doses less than 10 mg were allegedly associated with such dysrhythmias are reviewed in detail. Confounding issues present in a majority of the cases make it difficult to incriminate droperidol as the likely cause of the reported adverse events.

Postoperative nausea and vomiting after total intravenous anesthesia with propofol and remifentanil or alfentanil: how important is the opioid?

Study Objective: To compare the frequency and duration of postoperative nausea and vomiting (PONV) following total intravenous anesthesia (TIVA) with propofol and either remifentanil or alfentanil in outpatients undergoing arthroscopic surgery of the extremities.

Design: Randomized, third-party blinded study.

Setting: University medical center.

Pharmacokinetics and pharmacodynamics of inhaled versus intravenous morphine in healthy volunteers.

Background: A new pulmonary drug delivery system produces aerosols from disposable packets of medication. This study compared the pharmacokinetics and pharmacodynamics of morphine delivered by an AERx prototype with intravenous morphine.

Methods: Fifteen healthy volunteers were enrolled.

Dolasetron for the prevention of postoperative nausea and vomiting following outpatient surgery with general anaesthesia: a randomized, placebo-controlled study. The Dolasetron PONV Prevention Study Group.

In a multicentre, randomized, double-blind, placebo-controlled dose-ranging study, 1030 patients undergoing outpatient surgery with general anaesthesia received i.v. dolasetron mesylate (12.

A randomized, double-blind, dose-response study of ondansetron in the prevention of postoperative nausea and vomiting.

Study Objective: To determine the dose-response relationship of ondansetron in preventing postoperative nausea and vomiting (PONV) in women undergoing elective surgery.

Design: Prospective, randomized, double-blind study.

Setting: University-affiliated hospital.

Bispectral analysis of the electroencephalogram predicts conscious processing of information during propofol sedation and hypnosis.

Background: The bispectral index (BIS) measures changes in the interfrequency coupling of the electroencephalogram (EEG). The purposes of this study were (1) to determine whether BIS correlates with responses to command during sedation and hypnosis induced by propofol or propofol and nitrous oxide, and (2) to compare BIS to targeted and measured concentrations of propofol in predicting participants' responses to commands.

Methods: Twenty volunteers (15 men and 5 women, aged 22-50 yr) were given propofol by computer-controlled infusion, and EEG was recorded for off-line analysis of BIS.

Pharmacokinetics and pharmacodynamics of remifentanil in persons with renal failure compared with healthy volunteers.

Background: Remifentanil is an opioid analgesic for use in anesthesia. An ester linkage renders it susceptible to rapid metabolism by blood and tissue esterases. Thus it was hypothesized that remifentanil elimination would be independent of renal function.

Pharmacokinetics and pharmacodynamics of remifentanil in volunteer subjects with severe liver disease.

Background: Remifentanil, a new mu-opioid agonist with an extremely short duration of action, is metabolized by circulating and tissue esterases; therefore, its clearance should be relatively unaffected by changes in hepatic or renal function. This study was designed to determine whether severe hepatic disease affects the pharmacokinetics or pharmacodynamics of remifentanil.

Methods: Ten volunteers with chronic, stable, severe hepatic disease and awaiting liver transplantation and ten matched controls were enrolled.

Initial clinical experience with remifentanil, a new opioid metabolized by esterases.

Remifentanil is a new, esterase-metabolized opioid for anesthesia. Nonspecific esterases terminate the drug effect, with a context-sensitive half-time which plateaus at 3-4 min. This dose-ranging pilot study was designed to estimate the dose requirement of remifentanil for abolition of the responses to skin incision and intraoperative stimuli, and to determine the speed of recovery.

A randomized, double-blind pilot study examining the use of intravenous ondansetron in the prevention of postoperative nausea and vomiting in female inpatients.

Study Objective: To compare the efficacy and safety profiles of intravenous (IV) ondansetron (two 8 mg doses 8 hours apart) and a placebo when used in the prevention of postoperative nausea and emesis (vomiting or retching).

Design: Randomized, double-blind, placebo-controlled, parallel, multicenter pilot study.

Setting: Four university hospitals in the United States.

Ondansetron does not affect alfentanil-induced ventilatory depression or sedation.

Ondansetron is a selective 5-hydroxytryptamine type 3 receptor antagonist effective as an antiemetic in patients experiencing post-operative or cancer chemotherapy-induced nausea and vomiting. Currently, no information is available regarding the interaction of ondansetron with opioids, although a serotonin antagonist might be expected to modify some opioid actions. This study was designed to measure the effects of ondansetron on alfentanil-induced ventilatory depression and sedation in healthy male volunteers.

Ondansetron is effective in decreasing postoperative nausea and vomiting.

The efficacy of ondansetron, a selective 5-HT3 receptor antagonist, in preventing postoperative nausea and vomiting in surgical patients was studied. Fifty women were randomized in a double-blind manner to receive either two 8 mg doses of intravenous ondansetron or two doses of placebo vehicle: the first given just before general anesthesia induction and the second 8 hours later. During the first 24 postoperative hours, the number of emetic episodes was recorded and the subjects rated their nausea on a scale from 0 to 10.

Comparison of the sedative effects of butorphanol and midazolam.

Although kappa opioid agonists and certain agonist-antagonists are known to be sedating, this effect has not been well characterized in a drug-naive population. We compared the sedative properties of intravenous butorphanol with those of midazolam or the combination in 126 healthy preoperative patients. Subjects were randomly assigned to receive one of nine treatments in a double-blind fashion: 7.

Acute myocardial infarction symptoms masked by epidural morphine?

This report describes the case of an 80-year-old woman with a long history of chronic, stable angina pectoris who underwent resection of an abdominal aortic aneurysm and placement of an aortobifemoral bypass graft under a combination of epidural and general anesthesia. Epidural morphine was administered postoperatively for pain management. The patient suffered a massive myocardial infarction (MI) in the immediate postoperative period but experienced no chest pain or discomfort similar to her usual anginal symptoms.

Azumolene reverses episodes of malignant hyperthermia in susceptible swine.

Azumolene is an analogue of dantrolene with much greater water solubility. Ten swine susceptible to malignant hyperthermia (MH) were triggered into MH episodes via the inhalation of halothane, and azumolene was effective in terminating all of the MH episodes. There was an inverse relationship between the dose of azumolene required to terminate the MH episode and the time it took for the pig to manifest the signs of MH.

Ketamine does not trigger malignant hyperthermia in susceptible swine.

The use of ketamine in individuals susceptible to malignant hyperthermia (MH) is controversial. We describe our experience with ketamine used for induction and/or maintenance of anesthesia in our herd of swine inbred for susceptibility to MH. A total of 76 MH-susceptible swine were given a total of 112 general anesthetics using ketamine as the induction drug.

Safety of amide local anesthetics in patients susceptible to malignant hyperthermia.

Earlier reports on malignant hyperthermia warned against the use of local anesthetics in the amide class in persons susceptible to the syndrome. The preponderance of data supports the safety of amide local anesthetics in such patients, and these agents should not be withheld from persons at risk for developing the syndrome.

Metabolic and morphologic effects of the antimicrobial agent nitrofurantoin on human erythrocytes in vitro.

We have reported previously that the antimicrobial nitrofurantoin stimulates superoxide production and methemoglobin formation from HbO2 as an isolated hemeprotein and in hemolysates [M. Dershwitz and R. F.

Studies on the mechanism of nitrofurantoin-mediated red cell toxicity.

The mechanism of nitrofurantoin-mediated depletion of red cell reduced glutathione (GSH) was investigated. Nitrofurantoin caused cellular depletion of GSH in vitro under aerobic and oxygen-depleted conditions, an effect which could be partially inhibited by coincubation with the hemeprotein ligand ethyl isocyanide, or completely prevented by coincubation with 2'-AMP, an inhibitor of NADPH-dependent reductase enzymes. Covalent binding of nitrofurantoin to red cell macromolecules appeared to be a minor process and was not substantially inhibited by either ethyl isocyanide or 2'-AMP.

Generation of superoxide via the interaction of nitrofurantoin with oxyhemoglobin.

Nitrofurantoin was found to interact with HbO2 to cause the concomitant formation of methemoglobin and superoxide. The rate of formation of methemoglobin and superoxide was linearly dependent upon the concentration of nitrofurantoin and could be inhibited by superoxide dismutase, catalase, or the prior conversion of HbO2 to ethylioscyanoferrohemoglobin. The ability of nitrofurantoin to interact with HbO2 and cause superoxide formation may represent one mechanism by which it produces red cell toxicity and suggests that generation of superoxide in erythrocytes may occur via a different mechanism than that which occurs in microsomes.