title: Hemodynamic responses to intravascular injection of epinephrine-containing epidural test doses in adults during general anesthesia.
abstract: BACKGROUND
  Epidural anesthesia is sometimes initiated during general anesthesia, yet few data exist concerning efficacy of epinephrine-containing test doses.
  
  
  METHODS
  Thirty-six patients were randomized to receive either 0.5 MAC isoflurane, 1 MAC isoflurane, or 0.5 MAC each (1 MAC total) of isoflurane and nitrous oxide. Each subject received intravenous saline followed by three test doses containing 45 mg lidocaine with 7.5, 15, and 30 micrograms epinephrine in a randomized, double-blind fashion. Heart rate and systolic, diastolic, and mean blood pressures were measured for 5 min after injection. Positive hemodynamic criteria identifying intravascular injection were determined from peak increases in hemodynamics during administration of saline. Dose-effect relationships between epinephrine and peak increases in hemodynamics were assessed with linear regression. Minimum required doses of epinephrine to produce peak positive hemodynamic increases on average were determined from linear regression.
  
  
  RESULTS
  Positive hemodynamic criteria were identified as increases in heart rate > or = 8 beats/min, systolic blood pressure > or = 13 mmHg, diastolic blood pressure > or = 7 mmHg, and mean blood pressure > or = 9 mmHg. Significant dose-effect relationships were observed for epinephrine and peak increases in hemodynamics (correlation coefficients ranged from 0.61-0.91). Minimum required doses of epinephrine ranged from 6 to 19 micrograms depending on hemodynamic measurement and anesthetic group.
  
  
  CONCLUSIONS
  Hemodynamic responses to intravascular injection of test doses vary with dose of epinephrine and depth and type of general anesthetic used. Thus, the 15 micrograms epinephrine contained in the standard test dose may not be sufficient during all anesthetic conditions.
authors.affiliation: Department of Anesthesiology, Virginia Mason Medical Center, Seattle, Washington 98111, USA. anessl@vmmc.org
authors.forename: S S
authors.initials: SS
authors.lastname: Liu
authors.forename: R L
authors.initials: RL
authors.lastname: Carpenter
mesh_terms: D000328:Adult; D000767:Anesthesia, Epidural / Q000379:methods; D000768:Anesthesia, General / Q000379:methods*; D018685:Anesthetics, Inhalation; D001831:Body Temperature / Q000187:drug effects; D004305:Dose-Response Relationship, Drug; D004311:Double-Blind Method; D004837:Epinephrine / Q000008:administration & dosage*; D005260:Female; D006439:Hemodynamics / Q000187:drug effects*; D006801:Humans; D007268:Injections, Epidural; D007275:Injections, Intravenous; D007530:Isoflurane; D008297:Male; D009609:Nitrous Oxide
chemical_list: D018685:Anesthetics, Inhalation; D007530:Isoflurane; D009609:Nitrous Oxide; D004837:Epinephrine