The complication of postoperative nausea and vomiting is still one of the most common today. The potential for secondary complications associated with retching and vomiting such as aspiration pneumonitis strain of suture line with possible hemorrhage, and potential fluid and electrolyte imbalance makes prevention of retching and vomiting a primary concern in the management of the postoperative patient. The use of antiemetic drugs to prevent or control postoperative nausea and vomiting is a long-standing practice. Droperidol, an antiemetic, routinely used since being introduced in 1963, has been found to be successful in treating postoperative nausea and vomiting. This study examines the effect of droperidol .018 mg/kg given intramuscularly one half hour prior to the end of anesthesia on postoperative emesis in the adult gynecological patient presenting for total abdominal hysterectomy. Twelve patients were in this double-blind study, six acted as controls and six were in the experimental group. All subjects were premedicated with morphine sulfate 0.1 mg/kg and glycopyrrolate 0.2 mg, intramuscularly administered. All were induced with pentathol 4 mg/kg preceded by curare 3 mg and followed by succinylcholine 1.5 mg/kg for intubation. The subjects were maintained on isoflurane, sixty percent nitrous in oxygen, and pancuronium for relaxation. The subjects were of similar age and weight. Duration of anesthesia was similar with a mean of 2.93 hours overall. The incidence of retching or vomiting was considered as the same result. The droperidol group had one subject retch only and another retch and vomit. This gave a 33 percent incidence of retching and vomiting. The control group had three subjects retch and vomit, giving a 50 percent incidence. The small sample size provided no statistical significance. The results showed a trend of decreased vomiting in the adult subject presenting for total abdominal hysterectomy. The routine use of droperidol in this particular population cannot be recommended from these results.

O presente estudo objetivou comparar a eficácia analgésica entre dois tipos de técnicas anestésicas (tópica e tópica associada a crioanalgesia) utilizadas para realização da cirurgia de catarata. Vinte e cinco pacientes com catarata senil em ambos os olhos, classificadas de acordo com o critério de LOCS III em NO3 NC3 e NO4 NC4, acuidade visual inferior a 20/40 e indicação cirúrgica foram randomizados para serem submetidos à facoemulsificação com uso de solução de irrigação ocular em temperatura ambiente (23°C) em um olho (Grupo 1; n = 25) e gelada (4°C) no olho contralateral (Grupo 2; n = 25). A dor do procedimento foi avaliada através do uso de escala analógica visual 15 minutos após a realização da facoemulsificação. Esta escala varia de 0 a 100, onde o ponto 0 representa nenhuma dor e 100 representa a dor mais intensa que poderia ter sentido durante todo o procedimento cirúrgico. A perda celular endotelial, a variação da espessura corneana e o ganho de visão foram avaliados 30 ± 2 dias após cada cirurgia. A média da dor no Grupo 1 foi de 26.02 (DP=18.58) e no Grupo 2 foi de 21.28 (DP=18.20). Os valores das medianas da dor relacionada ao procedimento nos grupos 1 e 2 foram, respectivamente, 22.5 (0 66.5) e 17 (0 75.5). Após um mês de acompanhamento, a perda média de células endoteliais foi de 10% e 9.88% respectivamente, não havendo diferença estatisticamente significativa entre os grupos (teste de Wilcoxon). Não houve correlação estatisticamente significativa entre os valores médios de tempo de cirurgia, volume de irrigação, tempo de ultrassom, poder de ultrassom e ganho de visão com a perda celular ou com o escore de dor (análise de correlação de mínimos quadrados). O estudo demonstrou que não houve diferença no controle da intensidade da dor durante o procedimento de facoemulsificação com o uso de anestesia tópica ou anestesia tópica associada à crioanalgesia. / The study aimed to compare the analgesic efficacy between two types of anesthetic techniques (topical and topical associated with cryoanalgesia) during cataract surgery. Twenty-five patients with senile bilateral cataract, classified in NO3 NC3 and NO4 NC4 according to LOCS III criteria, visual acuity less than 20/40 and surgical indication were randomized to undergo phacoemulsification with the use of ocular irrigation solution at room temperature (23°C) for an eye (Group 1, n = 25) and cold solution in the contralateral eye (Group 2, n = 25). The pain of the procedure was assessed by using a visual analogue scale 15 minutes after the completion of phacoemulsification. This scale ranges from 0 to 100, being the point \"0\" representation of \"no pain\" and \"100\" the \"worst pain you might have felt\" throughout the surgical procedure. Endothelial cell loss, change in corneal thickness and vision improvement were evaluated 30 ± 2 days after each surgery. Operation time, irrigation volume, ultrasound time and ultrasound power were related to cell loss between groups. Mean pain in Group 1 was 26.02 (SD=18.58) and in Group 2 was 21.28 (SD=18.20). Median (range) pain related to the procedure in groups 1 and 2 were, respectively, 22.5 (066.5) and 17 (075.5). After one month follow-up, the mean endothelial cell loss was 10% and 9.88% respectively, with no statistical difference between groups. There were no statistically significant correlation between surgery time, irrigation volume, ultrasound time, ultrasound power and vision improvement means with cell loss or pain scores (bivariate fit). Study showed no difference in controlling the intensity of pain during phacoemulsification with the use of topical anesthesia or topical anesthesia associated with cryoanalgesia.

Sleep disruption has been implicated in morbidity after major surgery since 1974. Sleep-related upper airway obstruction has been associated with death after upper airway surgery and profound episodic hypoxaemia in the early postoperative period. There is also evidence for a rebound in rapid eye movement (REM) sleep that might be contributing to an increase in episodic sleep-related hypoxaemic events later in the first postoperative week. Speculation regarding the role of REM sleep rebound in the generation of late postoperative morbidity and mortality has evolved into dogma without any direct evidence to support it. The research presented in this thesis involved two main areas: a search for evidence of a clinically important contribution of REM sleep rebound to postoperative morbidity, and a re-examination of the role of sleep in the causation of postoperative episodic hypoxaemic events. To assess the latter, a relationship between airway obstruction under anaesthesia and the severity of sleep-disordered breathing was sought. In 148 consecutive sleep clinic patients, 49% of those with sleep-disordered breathing (SDB) had a number of events in non-rapid eye movement sleep (NREM) that was greater than or equal to that in REM and 51% had saturation nadirs in NREM that were equal to or worse than their nadirs in REM. This suggests SDB is not a REM-predominant phenomenon for most patients. Of 1338 postoperative deaths occurring over 6.5 years in one hospital only 37 were unexpected, most of which were one or two days after surgery with no circadian variation in the time of death, casting further doubt on the potential role of REM rebound. Five of nine subjects studied preoperatively had moderately severe SDB. Unrecognised and significant SDB is common in middle-aged and elderly patients presenting for surgery suggesting overall perioperative risk of important adverse events from SDB is probably small. In 17 postoperative patients, sleep macro-architecture was variably altered with decreases in REM and slow wave sleep while stage 1 sleep and a state of pre-sleep onset drowsiness, both associated with marked ventilatory instability, were increased. Sleep micro-architecture was also changed with an increase in power in the alpha-beta electroencephalogram range. These micro-architectural changes result in ambiguity in the staging of postoperative sleep that may have affected the findings of this and other studies. Twenty-four subjects with airway management difficulty under anaesthesia were all found to have some degree of SDB. Those with the most obstruction-prone airways while anaesthetised had a very high incidence of severe SDB. Such patients warrant referral to a sleep clinic.

Sleep disruption has been implicated in morbidity after major surgery since 1974. Sleep-related upper airway obstruction has been associated with death after upper airway surgery and profound episodic hypoxaemia in the early postoperative period. There is also evidence for a rebound in rapid eye movement (REM) sleep that might be contributing to an increase in episodic sleep-related hypoxaemic events later in the first postoperative week. Speculation regarding the role of REM sleep rebound in the generation of late postoperative morbidity and mortality has evolved into dogma without any direct evidence to support it. The research presented in this thesis involved two main areas: a search for evidence of a clinically important contribution of REM sleep rebound to postoperative morbidity, and a re-examination of the role of sleep in the causation of postoperative episodic hypoxaemic events. To assess the latter, a relationship between airway obstruction under anaesthesia and the severity of sleep-disordered breathing was sought. In 148 consecutive sleep clinic patients, 49% of those with sleep-disordered breathing (SDB) had a number of events in non-rapid eye movement sleep (NREM) that was greater than or equal to that in REM and 51% had saturation nadirs in NREM that were equal to or worse than their nadirs in REM. This suggests SDB is not a REM-predominant phenomenon for most patients. Of 1338 postoperative deaths occurring over 6.5 years in one hospital only 37 were unexpected, most of which were one or two days after surgery with no circadian variation in the time of death, casting further doubt on the potential role of REM rebound. Five of nine subjects studied preoperatively had moderately severe SDB. Unrecognised and significant SDB is common in middle-aged and elderly patients presenting for surgery suggesting overall perioperative risk of important adverse events from SDB is probably small. In 17 postoperative patients, sleep macro-architecture was variably altered with decreases in REM and slow wave sleep while stage 1 sleep and a state of pre-sleep onset drowsiness, both associated with marked ventilatory instability, were increased. Sleep micro-architecture was also changed with an increase in power in the alpha-beta electroencephalogram range. These micro-architectural changes result in ambiguity in the staging of postoperative sleep that may have affected the findings of this and other studies. Twenty-four subjects with airway management difficulty under anaesthesia were all found to have some degree of SDB. Those with the most obstruction-prone airways while anaesthetised had a very high incidence of severe SDB. Such patients warrant referral to a sleep clinic.

O presente estudo objetivou comparar a eficácia analgésica entre dois tipos de técnicas anestésicas (tópica e tópica associada a crioanalgesia) utilizadas para realização da cirurgia de catarata. Vinte e cinco pacientes com catarata senil em ambos os olhos, classificadas de acordo com o critério de LOCS III em NO3 NC3 e NO4 NC4, acuidade visual inferior a 20/40 e indicação cirúrgica foram randomizados para serem submetidos à facoemulsificação com uso de solução de irrigação ocular em temperatura ambiente (23°C) em um olho (Grupo 1; n = 25) e gelada (4°C) no olho contralateral (Grupo 2; n = 25). A dor do procedimento foi avaliada através do uso de escala analógica visual 15 minutos após a realização da facoemulsificação. Esta escala varia de 0 a 100, onde o ponto 0 representa nenhuma dor e 100 representa a dor mais intensa que poderia ter sentido durante todo o procedimento cirúrgico. A perda celular endotelial, a variação da espessura corneana e o ganho de visão foram avaliados 30 ± 2 dias após cada cirurgia. A média da dor no Grupo 1 foi de 26.02 (DP=18.58) e no Grupo 2 foi de 21.28 (DP=18.20). Os valores das medianas da dor relacionada ao procedimento nos grupos 1 e 2 foram, respectivamente, 22.5 (0 66.5) e 17 (0 75.5). Após um mês de acompanhamento, a perda média de células endoteliais foi de 10% e 9.88% respectivamente, não havendo diferença estatisticamente significativa entre os grupos (teste de Wilcoxon). Não houve correlação estatisticamente significativa entre os valores médios de tempo de cirurgia, volume de irrigação, tempo de ultrassom, poder de ultrassom e ganho de visão com a perda celular ou com o escore de dor (análise de correlação de mínimos quadrados). O estudo demonstrou que não houve diferença no controle da intensidade da dor durante o procedimento de facoemulsificação com o uso de anestesia tópica ou anestesia tópica associada à crioanalgesia. / The study aimed to compare the analgesic efficacy between two types of anesthetic techniques (topical and topical associated with cryoanalgesia) during cataract surgery. Twenty-five patients with senile bilateral cataract, classified in NO3 NC3 and NO4 NC4 according to LOCS III criteria, visual acuity less than 20/40 and surgical indication were randomized to undergo phacoemulsification with the use of ocular irrigation solution at room temperature (23°C) for an eye (Group 1, n = 25) and cold solution in the contralateral eye (Group 2, n = 25). The pain of the procedure was assessed by using a visual analogue scale 15 minutes after the completion of phacoemulsification. This scale ranges from 0 to 100, being the point \"0\" representation of \"no pain\" and \"100\" the \"worst pain you might have felt\" throughout the surgical procedure. Endothelial cell loss, change in corneal thickness and vision improvement were evaluated 30 ± 2 days after each surgery. Operation time, irrigation volume, ultrasound time and ultrasound power were related to cell loss between groups. Mean pain in Group 1 was 26.02 (SD=18.58) and in Group 2 was 21.28 (SD=18.20). Median (range) pain related to the procedure in groups 1 and 2 were, respectively, 22.5 (066.5) and 17 (075.5). After one month follow-up, the mean endothelial cell loss was 10% and 9.88% respectively, with no statistical difference between groups. There were no statistically significant correlation between surgery time, irrigation volume, ultrasound time, ultrasound power and vision improvement means with cell loss or pain scores (bivariate fit). Study showed no difference in controlling the intensity of pain during phacoemulsification with the use of topical anesthesia or topical anesthesia associated with cryoanalgesia.

Improving patient safety through reduction of medical errors is a national priority. One of the strategies widely utilized to address this issue is the use of incident reporting systems. The purpose of this study was to describe factors that predict the likelihood that Certified Registered Nurse Anesthetists (CRNAs) will use incident reporting systems, guided by the theory of planned behavior (Ajzen, 1991). A non-experimental, correlational research design was utilized to achieve the study aims. Following IRB approval, a cross-sectional survey was administered electronically to a random sample of practicing CRNAs. Correlational analyses and a standard logistic regression were utilized to determine the relationship between cognitive factors and CRNAs' use of incident reporting systems. Two hundred and eighty-three practicing CRNAs participated in this study. These CRNAs value incident reporting, perceive social pressure to report, and feel in control over reporting, yet had not consistently used existing incident reporting systems in the past 12 months. A CRNA’s attitude toward reporting and the degree to which he or she perceived social pressure to report, were determined to be significant predictors of the likelihood that a CRNA would use an incident reporting system. Social pressure to report was the most important factor in the prediction model. The results of this study revealed that there are missed opportunities for learning from patient safety incidents in anesthesia practice. The information gained in this study has the potential to assist organizations in the design of strategies to promote incident reporting by practicing CRNAs.

Este é um estudo clínico, prospectivo, aleatório, e duplamente encoberto realizado em 40 crianças submetidas a cirurgia infra-umbilical de pequeno porte, sob anestesia epidural sacra realizada com a mistura enantiomérica de bupivacaína (S75R25) comparada com a bupivacaína racêmica (SR50) isoladas ou em associação com a clonidina. O objetivo foi avaliar a duração do bloqueio motor e sensitivo, o consumo de sevoflurano e as variações da pressão arterial sistólica (PAS) e freqüência cardíaca (FC). O bloqueio motor foi avaliado pela escala de Bromage, durante o período de oito horas de observação no pós-operatório. A analgesia foi avaliada pelos escores obtidos com escala objetiva para análise da dor e a duração da analgesia foi considerada como o tempo entre a administração do anestésico local no espaço epidural sacro e a primeira dose de analgésico administrado. Os resultados obtidos foram submetidos à análise estatística onde p< 0,05 foi considerado significante. Os resultados mostraram que houve aumento significativo do bloqueio motor somente na primeira hora quando a bupivacaína SR50 foi associada a clonidina, mas não ocorreu o mesmo com a bupivacaína S75R25. Em relação a analgesia não houve diferença significante entre a bupivacaína SR50 e a bupivacaína S75R25 associadas ou não à clonidina. Não houve diferença significativa no consumo de sevoflurano entre os grupos estudados quando a clonidina foi associada aos anestésicos. Os valores da PAS e FC no pós-operatório, nos grupos onde a clonidina foi associada com ambos anestésicos locais, foram inferiores em todos os momentos de avaliação, porém sem significância estatística / This is a prospective, randomized double-blind clinical trial performed in 40 children using an enantiomeric mixture of bupivacaine (S75R25) compared to racemic bupivacaine SR50 plain or associated with clonidine, to caudal blockade. The aim of this study was to investigate the motor and sensitive block, sevoflurane requirement, blood pressure (PAS) and heart rate (FC) in children scheduled to sub-umbelical surgeries. The motor block was evaluated by Bromage scale for eight hours during the postoperative period. The analgesia was evaluated postoperatively for eight hours by an objective pain scale and the analgesia duration was taken as the time between the local anesthetic administration into epidural space and the first analgesic rescue. The results obtained were submitted to statistical analysis test where p< 0,05 was considered significant. There was a significant increase in the motor block at first hour on postoperative period when bupivacaine SR50 was associated to clonidine, but it did not occurr with the enantiomeric mixture of bupivacaine S75R25. There was no difference between bupivacaine SR50 and bupivacaine S75R25 associated or not to clonidine regarding to analgesia duration. There was no difference in the requirement of sevoflurane between groups in spite of the clonidine admixture to the local anesthetics. There was an absolut decrease in the PAS and FC values on the postoperative evaluation, but it was not statistically significant

Background: Emerging evidence suggests that aerobic exercise and conditioned pain modulation may be advocated in treating patients with musculoskeletal pain. The effects of lower extremity aerobic exercise and conditioned pain modulation on evoked shoulder pain are not known. Purpose: To determine the acute effects of lower extremity aerobic exercise and conditioned pain modulation on outcomes of evoked shoulder pain from pain pressure threshold measurements. Study Design: Repeated measures. Methods: Thirty (30) healthy volunteers were tested over the course of two sessions. Session 1 consisted of collecting pain pressure threshold measurements over the infraspinatus before and immediately following a conditioned pain modulation with cool water. Session 2 consisted of collecting pain pressure threshold measurements over the infraspinatus before and immediately following a bout of lower extremity aerobic exercise on a recumbent stepper apparatus. Results: Pain pressure threshold was not significantly influenced by the conditioned pain modulation using cool water (p=0.725). Pain pressure threshold was significantly increased immediately following the lower extremity exercise session (P<0.001). Conclusion: Conditioned pain modulation with cool water did not produce any significant changes in pain pressure threshold. Lower extremity aerobic exercise acutely increased pain pressure threshold in participants with experimentally induced shoulder pain. Physical therapists may consider lower extremity aerobic exercise to produce short-term hypoalgesic effects and facilitate the application of more active interventions.

Este é um estudo clínico, prospectivo, aleatório, e duplamente encoberto realizado em 40 crianças submetidas a cirurgia infra-umbilical de pequeno porte, sob anestesia epidural sacra realizada com a mistura enantiomérica de bupivacaína (S75R25) comparada com a bupivacaína racêmica (SR50) isoladas ou em associação com a clonidina. O objetivo foi avaliar a duração do bloqueio motor e sensitivo, o consumo de sevoflurano e as variações da pressão arterial sistólica (PAS) e freqüência cardíaca (FC). O bloqueio motor foi avaliado pela escala de Bromage, durante o período de oito horas de observação no pós-operatório. A analgesia foi avaliada pelos escores obtidos com escala objetiva para análise da dor e a duração da analgesia foi considerada como o tempo entre a administração do anestésico local no espaço epidural sacro e a primeira dose de analgésico administrado. Os resultados obtidos foram submetidos à análise estatística onde p< 0,05 foi considerado significante. Os resultados mostraram que houve aumento significativo do bloqueio motor somente na primeira hora quando a bupivacaína SR50 foi associada a clonidina, mas não ocorreu o mesmo com a bupivacaína S75R25. Em relação a analgesia não houve diferença significante entre a bupivacaína SR50 e a bupivacaína S75R25 associadas ou não à clonidina. Não houve diferença significativa no consumo de sevoflurano entre os grupos estudados quando a clonidina foi associada aos anestésicos. Os valores da PAS e FC no pós-operatório, nos grupos onde a clonidina foi associada com ambos anestésicos locais, foram inferiores em todos os momentos de avaliação, porém sem significância estatística / This is a prospective, randomized double-blind clinical trial performed in 40 children using an enantiomeric mixture of bupivacaine (S75R25) compared to racemic bupivacaine SR50 plain or associated with clonidine, to caudal blockade. The aim of this study was to investigate the motor and sensitive block, sevoflurane requirement, blood pressure (PAS) and heart rate (FC) in children scheduled to sub-umbelical surgeries. The motor block was evaluated by Bromage scale for eight hours during the postoperative period. The analgesia was evaluated postoperatively for eight hours by an objective pain scale and the analgesia duration was taken as the time between the local anesthetic administration into epidural space and the first analgesic rescue. The results obtained were submitted to statistical analysis test where p< 0,05 was considered significant. There was a significant increase in the motor block at first hour on postoperative period when bupivacaine SR50 was associated to clonidine, but it did not occurr with the enantiomeric mixture of bupivacaine S75R25. There was no difference between bupivacaine SR50 and bupivacaine S75R25 associated or not to clonidine regarding to analgesia duration. There was no difference in the requirement of sevoflurane between groups in spite of the clonidine admixture to the local anesthetics. There was an absolut decrease in the PAS and FC values on the postoperative evaluation, but it was not statistically significant

Neuronal nicotinic acetylcholine receptors (nAChRs) are ligand-gated cation channels that most notably influence dopamine (DA) release. In this thesis, I examine the role of nAChRs in mediating DA-related behaviors such as movement and drug dependence. To accomplish this, I utilized a “gain-offunction” knock-in mouse (the Leu9’Ala line) containing agonist-hypersensitive α4* nAChRs (* indicates other nAChR subunits in addition to α4 are within the receptor complex) that renders receptors 50-fold more sensitive to nicotine and acetylcholine than wild-type (WT) receptors. I found that DHβE, a selective antagonist for α4β2* nAChRs, induced reversible and robust motor dysfunction characterized by hypolocomotion, akinesia, catalepsy, tremor, and clasping in Leu9’Ala but not WT mice. Reversal of the phenotype was achieved by targeting dopamine signaling. Blockade of mutant α4* nAChRs elicited activation of brain regions in the basal ganglia including dorsal striatum and substantia nigra pars reticulata indicated by c-Fos immunoreactivity. These data indicate that blocking α4* nAChRs in Leu9’Ala mice activates the indirect motor pathway resulting in a motor deficit. We also determined that α4* nAChRs involved in motor behaviors did not contain the α6 subunit, a nAChR subunit highly expressed in DAergic neurons suggesting that different nAChR subtypes modulating striatal DA release have separate functions in motor output. Conditioned place aversion and hypolocomotion, behaviors elicited during nicotine withdrawal, were also induced by DHβE in nicotine-naïve Leu9’Ala but not WT mice. Together these data suggest that DHβE globally reduces DA release in the CNS. In a separate project, I determined that α4* and α6* nAChRs modulate drug-induced hypnosis. Activation of nAChRs increased sensitivity to ketamine-induced hypnosis; whereas antagonizing nAChRs had the opposite effect. Additionally, α4 knockout (KO) mice were less sensitive to the hypnotic effects of ketamine, but α6 KO were more sensitive. High doses of ethanol induce an anesthesia-like state characterized by immobility, analgesia, and hypnosis. Testing the effects of ethanol hypnosis in α4 KO revealed that α4* nAChR do not play a large role in the acute effects of ethanol-induced hypnosis, but are involved in tolerance to this ethanol-induced behavior. The mechanisms of anesthetic-induced hypnosis are still largely unclear, despite the wide use of anesthesia. Future work on these receptors and their involvement in the anesthetic response will help to define a mechanism for hypnosis and improve the use of anesthetic drugs.