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Purpose: 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., Methods: 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., Results: 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, P < 0.001), and that for one-year mortality was 1.32 (95% CI = 1.21-1.43, P < 0.001)., Conclusions: 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.

Purpose: Nitrous oxide (N(2)O) is a frequently used adjunct to propofol anesthesia. Although N(2)O reduces the requirement of propofol for induction and maintenance, the effects of both drugs on overall hemodynamics remain controversial. We tested the hypothesis that the addition of N(2)O to therapeutic doses of propofol alters hemodynamics and Doppler-derived variables evaluated with the esophageal Doppler monitor in a randomized, double-blinded, placebo-controlled design., Methods: Thirty ASA I-II patients (aged 30-66 yr) were randomly assigned to receive propofol with oxygen-enriched air (FIO(2) = 0.3; air group) or propofol with 70% N(2)O (N(2)O group). Following intubation, a computerized target-controlled infusion technique was used to administer propofol from 0 micro g x mL(-1) (baseline) to 5 micro g x mL(-1) in 1 micro g x mL(-1) increments., Results: Mean arterial pressure (MAP) decreased more in the N(2)O group than in the air group only at 5 micro g x mL(-1). Aortic blood flow (ABF) showed a similar dose-dependent decrease in both groups. Peak aortic flow acceleration, as a myocardial contractility index, decreased significantly and similarly in both groups in a dose-dependent manner whereas peak velocity of ABF, as another measure of myocardial contractility, remained unchanged. Heart rate-corrected left ventricular ejection time, as a measure of preload, remained constant in both groups at any target plasma concentration., Conclusion: Propofol causes dose-dependent decreases in ABF and MAP; however, 70% N(2)O produces minimal hemodynamic and Doppler-derived variable changes under target-controlled propofol infusion at therapeutic concentrations.

Purpose: To determine whether epidural lidocaine reduces the severity of propofol injection pain compared with iv lidocaine., Methods: A prospective, randomized double-blind clinical study was conducted in 120 female patients scheduled for elective gynecological laparotomy. A lumbar epidural catheter and an iv catheter placed in the cephalic vein of the non-dominant hand were used in all patients. Patients of the control group (Group C) were given epidural normal saline followed by iv normal saline then iv propofol. Patients of Group E were given epidural 2% lidocaine (0.08 mL.cm(-1)) followed by iv normal saline and then propofol. Patients of Group V were given epidural normal saline followed by iv 2% lidocaine (0.05 mL.kg(-1)) then propofol. Pain was scored as no pain=0, minimal pain=1, moderate pain=2, severe pain=3., Results: The pain scores, in group E; 1 (0-2) and group V; 2 (0-2), were significantly lower than in group C; 2 (1-3); median (25th-75th percentile) (P <0.001). There was no difference in pain score between groups E and V The plasma lidocaine concentration 15 min after epidural lidocaine was 2.74 +/- 0.54 microg.ml(-1), compared with 1.54 +/- 0.31 microg.mL(-1) at three minutes after iv lidocaine., Conclusion: Epidural and iv lidocaine equally reduced the severity of propofol injection pain despite higher lidocaine plasma concentrations in epidurally administered lidocaine.

Purpose: We describe the anesthetic management of a patient with pulmonary lymphangiomyomatosis (LAM) during thoracoscopic lung biopsy (TSLB)., Clinical Features: LAM is a rare idiopathic disease characterised by progressive deterioration in respiratory function, occurring almost exclusively in women. In establishing the diagnosis, an open lung biopsy (OLB) has been employed in patients with relatively normal lung function. However, TSLB rather than OLB is less invasive. A 38 yr old woman developed a clinical course of cough, shortness of breath and sputum production, Chest X-ray findings, 99mTc-MAA scintigraphy and thin-sliced high resolution CT, typical of LAM, TSLB was scheduled to establish the diagnosis. General anesthesia, employing differential lung ventilation and high frequency jet ventilation combined with epidural anesthesia and continuous intravenous propofol was performed successfully. High frequency ventilation was applied to the non-dependent lung and intermittent positive pressure ventilation (IPPV) to the dependent lung with lower tidal volume and respiratory rate, allowing permissive hypercapnia. In the postoperative period, although synchronized intermittent mandatory ventilation was applied, pressure support ventilation or continuous positive airway pressure (CPAP) would have been a better selection. Postoperative sedation was performed satisfactorily using propofol., Conclusions: We recommend general anesthesia using differential lung ventilation combined with epidural anesthesia and intravenous propofol during TSLB for LAM. Postoperative ventilation should be pressure support ventilation or CPAP to keep peak inspiratory pressure low and allow permissive hypercapnia.

Purpose: To determine whether the continuous low thoracic extradural administration of the same dose of lidocaine at low concentration with a high infusion rate or at high concentration with a low infusion rate in combination with a fixed dose of buprenorphine (0.4 mg.day-1) modifies postoperative pain relief., Methods: Twenty-eight patients undergoing elective upper abdominal surgery were randomly allocated to one of two groups to receive lidocaine 2%--buprenorphine at a rate of 6.3 ml.hr-1 (2% group, n = 13) or lidocaine 6%-buprenorphine at a rate of 2.1 ml.hr-1 (6% group, n = 15). During suture of the peritoneum, mepivacaine 2% (8 ml) with 0.1 mg (0.5 ml) buprenorphine was infused extradurally. After extubation, the continuous extradural infusion was initiated. Patients were assessed for the level of analgesia with the 10 cm VAS score at rest and with the Prince Henry Pain Scale (PHPS) at 3, 6, 9, 12, 18, and 24 hr postoperatively., Results: The visual analogue scale (VAS) scores at rest did not differ between the two groups except at 18 hr after surgery. The Prince Henry Pain Scale (PHPS) scores were not different between the two groups postoperatively., Conclusion: There was no difference in analgesia produced by the continuous extradural infusion of lidocaine 2%-buprenorphine at a rate of 6.3 ml.hr-1 and that of lidocaine 6%-buprenorphine at a rate of 2.1 ml.hr-1 following upper abdominal surgery.