piperidines and Emergencies

Minor traumatic injuries are common in pregnancy, often subsequently requiring painful diagnostic and therapeutic procedures. Pregnant women who are experiencing significant pain, distress, or fear may benefit from procedural sedation in the emergency department. In this review we examine the fetal safety of specific drugs used for procedural sedation.

Topics: Anesthesia; Emergencies; Female; Fetus; Humans; Hypnotics and Sedatives; Ketamine; Midazolam; Piperidines; Pregnancy; Pregnancy Complications; Propofol; Remifentanil; Wounds and Injuries

Aspiration is a significant cause of anesthetic morbidity, occurring most commonly during the induction of anesthesia. For patients with a high likelihood of aspiration, rapid sequence intubation (RSI) techniques may minimize this risk by reducing the time between the loss of protective airway reflexes and the placement of a cuffed endotracheal tube. Although RSI frequently involves the administration of a neuromuscular-blocking agent (NMBA) such as succinylcholine or rocuronium, there are times when the administration of an NMBA is contraindicated or undesirable. We present an 11-year-old boy who presented with vomiting, papilledema, and a history concerning for an undiagnosed neuromuscular disorder. Deep sedation or anesthesia was required during an emergent lumbar puncture to evaluate his symptoms. Rapid sequence intubation was successfully performed with propofol and remifentanil without the use of an NMBA. We highlight the anesthetic considerations in such a clinical scenario and review the literature regarding the combination of remifentanil and propofol for RSI.

Topics: Anesthesia, Inhalation; Child; Contraindications; Deep Sedation; Emergencies; Headache; Humans; Hypnotics and Sedatives; Intracranial Hypertension; Intubation, Intratracheal; Laryngoscopy; Male; Methyl Ethers; Muscle Weakness; Neuromuscular Depolarizing Agents; Neuromuscular Diseases; Piperidines; Propofol; Remifentanil; Respiratory Aspiration of Gastric Contents; Risk; Sevoflurane; Spinal Puncture; Succinylcholine; Vision Disorders; Vomiting

The importance of glucose control in reducing the complications of diabetes mellitus has been clearly demonstrated. The emergency physician routinely is expected to treat a wide range of problems related to this disease, including making the initial diagnosis of type 2 and occasionally type 1 diabetes. Also common are patients with poorly controlled diabetes. The recent introduction of new classes of agents to lower blood glucose, especially in type 2 diabetes, should improve the control in this category of patient and reduce the complication rate. Some of these agents, such as troglitazone, have potentially fatal complications and require careful monitoring. Emergency physicians should be aware of the common complications of these drugs because patients can present to the ED with them. Hypoglycemia, a common cause of 911 calls and emergency visits, is not a side effect of either metformin or acarbose. Insulin lispro has improved postprandial glycemic control for type 1 and some insulin-requiring type 2 diabetics. Hypoglycemia is less of a risk with insulin lispro, and quality of life is better with this rapidly acting insulin. Newer methods of insulin delivery, such as continuous subcutaneous infusion, have greatly improved glucose control, given greater freedom to patients, and reduced the risks of hypoglycemia.

Topics: Acarbose; Administration, Oral; Carbamates; Chromans; Diabetes Mellitus; Drug Overdose; Emergencies; Humans; Hypoglycemic Agents; Insulin; Insulin Lispro; Metformin; Piperidines; Sulfonylurea Compounds; Thiazoles; Thiazolidinediones; Troglitazone

Topics: Acute Disease; Adult; Anesthesia, General; Cholecystectomy; Cholecystitis; Emergencies; Humans; Intraoperative Complications; Male; Mitochondrial Encephalomyopathies; Monitoring, Intraoperative; Piperidines; Postoperative Complications; Propofol; Remifentanil

Short acting beta-blockers (SBB) have been utilized effectively to prevent adverse cardiac events perioperatively. After recent introduction of remifentanil in Japan, applications of SBB could have been changed because of its intense analgesic and negative chronotrophic effects. Thus, we evaluated the factors that require SBB during general anesthesia using remifentanil.. Total of 1,631 patients who had general anesthesia with remifentanil were enrolled. Groups were divided by the use of SBB. Using logistic multivariable analysis, the factors significantly increasing the chance of using SBB were evaluated including patients' characteristics, surgical procedures, and anesthetic methods. A P value < 0.05 was considered as statistical significance.. One hundred thirty one patients received SBB perioperatively, 94 of them received only when awake and 34 of them received during remifentanil anesthesia. Emergency operation and preoperative ECG abnormalities were significant factors requiring SBB during anesthesia using remifentanil (OR; 3.0, 4.9 respectively).. Even with use of remifentanil there are the patients, such as those under emergency operation or with ECG abnormalities who require SBB perioperatively.

Topics: Adrenergic beta-Antagonists; Anesthesia, General; Emergencies; Female; Humans; Male; Middle Aged; Perioperative Period; Piperidines; Remifentanil; Tachycardia

A 70-year-old woman underwent emergent clipping surgery for subarachnoid hemorrhage under general anesthesia. Her laboratory data showed thrombocytopenia (4.0 x 10(4) microl(-1)). She had taken prednisolone (3 mg x day(-1)) and methotrexate (MTX) (10 mg x week(-1)) for rheumatoid arthritis for the last 10 years. Anesthesia was induced with remifentanil as well as propofol, maintained with remifentanil and sevoflurane in oxygen. The operation was performed uneventfully without platelet transfusion. Since the cause of thrombocytopenia was suspected to be MTX, we started rescue therapy by calcium folinate postoperatively. Platelet count was normalized two days later (11.6 x 10(4) microl(-1)). One month after the operation, she was discharged uneventfully.

Topics: Aged; Anesthesia, General; Arthritis, Rheumatoid; Emergencies; Female; Humans; Immunosuppressive Agents; Intracranial Aneurysm; Leucovorin; Methotrexate; Piperidines; Platelet Transfusion; Postoperative Care; Propofol; Remifentanil; Subarachnoid Hemorrhage; Thrombocytopenia; Treatment Outcome; Vascular Surgical Procedures

An 82-year-old female underwent emergency surgery for right femoral incarcerated hernia under general anesthesia. Anesthesia was induced and maintained with remifentanil and propofol. Her laboratory data showed severe hypokalemia (1.83 mEq x l(-1)) and metabolic alkalosis (HCO3 36.9 mmol x l(-1)). We suspected that the causes of such abnormalities were due to an endocrinological abnormality, but we could not ascertain the actual cause. Drip infusion of sodium chloride and saline solution infusion, to avoid supplying lactate or acetate, the source of bicarbonate ions, were chosen for palliative treatment. No adverse event occurred during surgery. After surgery, endocrinological functions were examined. Primary aldosteronism was ruled out because serum aldosterone and rennin activity were within normal ranges. The patient had been taking a Kampo preparation, Shakuyaku-kanzo-to, for two years. Glycyrrhizin, the main component of Shakuyaku-kanzo-to, has been reported to be a cause of pseudoaldosteronism by inhibiting the enzyme converting cortisol to cortisone. With these findings we confirmed that severe hypokalemia was induced by pseudoaldosteronism by long-term administration of Shakuyaku-kanzo-to.

Topics: Aged, 80 and over; Anesthesia, General; Drug Combinations; Drugs, Chinese Herbal; Emergencies; Female; Glycyrrhiza; Hernia, Femoral; Humans; Hypokalemia; Intraoperative Complications; Liddle Syndrome; Paeonia; Piperidines; Propofol; Remifentanil; Severity of Illness Index

Topics: Adult; Airway Management; Anesthesia, Inhalation; Anesthesia, Intravenous; Anesthesia, Obstetrical; Anesthesia, Spinal; Anesthetics, Local; Appendectomy; Appendicitis; Asthma; Cesarean Section; Charcot-Marie-Tooth Disease; Contraindications; Emergencies; Female; Humans; Middle Aged; Neuromuscular Depolarizing Agents; Neuromuscular Nondepolarizing Agents; Piperidines; Pregnancy; Pregnancy Complications; Propofol; Remifentanil

Obstructive ileus is a life-threatening gastrointestinal condition that requires emergency operation. Patients with obstructive ileus sometimes develop coagulopathy. In such cases, central neuraxial blockade should be avoided. Rectus sheath blockade (RSB) is one of the popular methods for abdominal wall surgery. Ultrasound imaging of the rectus sheath may facilitate successful RSB by indicating the presence and location of rectus abdominis. Two patients presented with ileus secondary to rectal or sigmoid cancer and underwent emergency ileostomy. The patients had mild coagulopathy [platelet count, 77,000 microl(-1) in case 1, and platelet count, 98,000 microl(-1) in case 2]. Each patient underwent general anesthesia using propofol and remifentanil. They were given 0.5% ropivacaine 20ml for RSB under ultrasound-guidance. Their hemodynamics was stable and they did not need another muscle relaxant during operation, except succinylcholine during induction. RSB is useful for abdominal operations. In addition, ultrasonogrhaphy facilitates the prediction of depth of the posterior rectus sheath and improves the accuracy of local anesthetic placement. We conclude that RSB is effective for improving postoperative pain and intraoperative muscle relaxation of the abdominal wall. Ultrasound-guided RSB is an alternative method to central neuraxial blockade.

Topics: Aged, 80 and over; Anesthesia, General; Blood Coagulation Disorders; Emergencies; Female; Humans; Ileostomy; Ileus; Male; Nerve Block; Perioperative Care; Piperidines; Propofol; Rectal Neoplasms; Rectus Abdominis; Remifentanil; Sigmoid Neoplasms; Ultrasonography

We present an emergency anesthetic management of craniotomy for a 22-year-old man with congenital cyanotic heart disease due to brain abscess. Pulmonary blood flow was completely supplied via major arteriopulmonay collatelal artery (MAPCA). This patient complicated with Eisenmenger syndrome, has no history of cardiac surgery but several times of craniotomy due to repeated brain abscess. Total intravenous anesthesia with propofol and remifentanil was induced and maintained. SpO2 and PaO2 were elevated after oxygen administration via mask. Although systemic blood pressure level was decreased by anesthesia and continuous infusion of vasopressors was required. Oxygenation parameters were unchanged. This indicates that blood flow through MAPCA did not respond to changes in of respiratory and circulatory circumstances during anesthesia.

Topics: Anesthesia, Intravenous; Brain Abscess; Craniotomy; Cyanosis; Eisenmenger Complex; Emergencies; Heart Defects, Congenital; Humans; Intraoperative Care; Male; Piperidines; Propofol; Recurrence; Remifentanil; Vasoconstrictor Agents; Young Adult

Topics: Adult; Anesthesia, Conduction; Anesthesia, General; Anesthesia, Obstetrical; Brain Edema; Cesarean Section; Contraindications; Emergencies; Female; Hemodynamics; Humans; Infant, Newborn; Intracranial Arteriovenous Malformations; Male; Piperidines; Pregnancy; Pregnancy Complications, Hematologic; Pregnancy Trimester, Third; Remifentanil; Respiratory Distress Syndrome, Newborn; Subarachnoid Hemorrhage; Vasospasm, Intracranial; Vertebral Artery

Topics: Adult; Anesthesia, General; Anesthesia, Obstetrical; Aorta; Aortic Aneurysm; Aortic Dissection; Atropine; Blood Vessel Prosthesis Implantation; Cesarean Section; Emergencies; Extracorporeal Circulation; Female; Fentanyl; Fetus; Hemodynamics; Humans; Infant, Newborn; Laparotomy; Piperidines; Pregnancy; Pregnancy Complications, Cardiovascular; Remifentanil; Succinylcholine

Topics: Adult; Analgesics, Opioid; Anesthesia, General; Anesthesia, Obstetrical; Anesthetics, Intravenous; Cesarean Section; Emergencies; Female; Humans; Piperidines; Porphyria, Acute Intermittent; Pregnancy; Pregnancy Complications; Remifentanil

Remifentanil is a synthetic opiate with evident advantages for various anesthetic techniques, enhancing quality of anesthesia. Indications are increasingly well-defined. Remifentanil may be used in obstetric analgesia-anesthesia thanks to advantages demonstrated in patients with heart disease (cardiac and non-cardiac anesthesia) and in those requiring neuroanesthesia. Remifentanil is known to cross the placenta rapidly and to be rapidly metabolized and redistributed to both mother and fetus. Based on this, and on pharmacokinetic and pharmacodynamic studies in children, we judged remifentanil to be indicated for use in two patients undergoing emergency cesarean section, for whom hemodynamic stability and immediate postoperative assessment were basic requirements. The first case involved a woman 40 weeks pregnant with a history of mitral valve prolapse and an episode of acute pulmonary edema in the 28th week, who presented with ruptured membrane and the fetus in sacroposterior breech presentation without subsequent progression of labor. The second involved a woman 40-weeks pregnant with a diagnosis of Hunt-Hess grade II subarachnoid hemorrhage who had gone into labor. Outcome was satisfactory in both cases, with no complications potentially affecting the status of either mother or child. No infant respiratory insufficiency occurred and Apgar scores were favorable. We consider remifentanil to be safe and effective for general anesthesia for emergency cesarean delivery in patients with cardiac and/or neurological risk factors.

Topics: Adult; Anesthesia, General; Anesthesia, Obstetrical; Anesthetics, General; Apgar Score; Cesarean Section; Emergencies; Female; Humans; Infant, Newborn; Intracranial Aneurysm; Maternal-Fetal Exchange; Mitral Valve Prolapse; Obstetric Labor Complications; Piperidines; Pregnancy; Pregnancy Complications, Cardiovascular; Pregnancy Complications, Hematologic; Pregnancy Outcome; Pulmonary Edema; Remifentanil; Subarachnoid Hemorrhage

We describe the use of remifentanil in a woman with severe pre-eclampsia who presented for emergency caesarean section. Remifentanil was effective in obtunding the hypertensive response to laryngoscopy and intubation. Previous studies have found no significant adverse effects of remifentanil on the neonate. With its short duration of action, the use of this new opioid has several potential advantages in the above setting. Further studies are required to explore the use of remifentanil as an adjunct to obstetric general anaesthesia.

Topics: Adult; Analgesics, Opioid; Anesthesia, General; Anesthesia, Obstetrical; Cesarean Section; Emergencies; Female; Humans; Hypertension; Intubation, Intratracheal; Liver; Piperidines; Pre-Eclampsia; Pregnancy; Pregnancy Complications; Remifentanil; Thrombocytopenia

We report the use of remifentanil as part of a general anaesthetic technique for a patient with mixed mitral valve disease, asthma and pre-eclampsia presenting for an emergency Caesarean section. The use of remifentanil was associated with stable haemodynamic variables during general anaesthesia. No clinically significant respiratory depression was noted in the neonate.

Topics: Analgesics, Opioid; Anesthesia, General; Anesthesia, Obstetrical; Cesarean Section; Emergencies; Female; Humans; Mitral Valve Insufficiency; Piperidines; Pregnancy; Pregnancy Complications, Cardiovascular; Remifentanil

Topics: Aged; Analgesics; Anaphylaxis; Benzophenones; Dipyrone; Drug Combinations; Drug Therapy, Combination; Emergencies; Female; Humans; Male; Middle Aged; Penicillin G; Penicillin G Benzathine; Penicillin G Procaine; Piperidines

Topics: Emergencies; Humans; Meprobamate; Piperidines; Promedol