The efficacy of simulated intravascular test dose in sedated patients.
Sedation usually decreases the reliability of subjectively detecting an intravascular test dose, but the efficacies of objective hemodynamic and T-wave criteria remain undetermined. Sixty healthy patients were randomly assigned to receive IV midazolam in 1-mg increments until they were lightly sedated, fentanyl 2 microg/kg followed by incremental midazolam until they were similarly sedated, or no sedative (n = 20 each). Then, normal saline 3 mL was administered IV, followed 4 min later by 1.5% lidocaine 3 mL plus epinephrine 15 microg (1:200,000) in all subjects. Heart rate (HR), systolic blood pressure (SBP) measured by a radial arterial catheter, and lead II of the electrocardiogram were continuously recorded for 4 min after the saline and test dose injections. An IV test dose produced significant increases in HR and SBP and decreases in T-wave amplitude in all subjects. However, the mean maximum increase in HR in patients sedated with midazolam plus fentanyl (31 +/- 14 bpm [mean +/- SD]) was significantly less than in those administered midazolam alone or no sedative (42 +/- 12 and 44 +/- 10 bpm, respectively; P < 0.05). A sensitivity of 100% was obtained on the basis of the traditional HR criterion (positive if > or =20 bpm increase) in patients sedated with midazolam or no sedative, but it was 70% in those with midazolam plus fentanyl (P < 0.05 versus the other two groups). Irrespective of the treatment, sensitivities and specificities of 100% were obtained according to the SBP (positive if > or =15 mm Hg increase) and T-wave (positive if > or =25% decrease in amplitude) criteria. An increase in SBP and a decrease in T-wave amplitude are more reliable than an HR response for detecting accidental intravascular injection of the epinephrine-containing test dose in subjects sedated with midazolam and fentanyl.


CONCLUSIONS
To determine whether an epidural catheter is in a blood vessel, an epidural test dose containing 15 microg epinephrine is used. We found that an increase in systolic blood pressure and a decrease in T-wave amplitude seem to be more reliable than a heart rate change for detecting inadvertent intravascular injection of an epinephrine-containing test dose in patients sedated with midazolam and fentanyl.
Tanaka
M
M
Department of Anesthesia, Akita University School of Medicine, Akita-City, Japan. mtanaka@med.akita-u.ac.jp
Sato
M
M
Kimura
T
T
Nishikawa
T
T
D000328:Adult; D000701:Analgesics, Opioid; D000779:Anesthetics, Local / Q000008:administration & dosage* / Q000009:adverse effects; D001794:Blood Pressure / Q000187:drug effects; D016292:Procedural Sedation; D004562:Electrocardiography / Q000187:drug effects; D004837:Epinephrine / Q000008:administration & dosage* / Q000009:adverse effects; D005260:Female; D005283:Fentanyl; D006339:Heart Rate / Q000187:drug effects; D006801:Humans; D006993:Hypnotics and Sedatives; D007262:Infusions, Intravenous; D007275:Injections, Intravenous; D008012:Lidocaine / Q000008:administration & dosage* / Q000009:adverse effects; D008297:Male; D008508:Medication Errors / Q000517:prevention & control*; D008874:Midazolam; D011446:Prospective Studies; D012680:Sensitivity and Specificity; D016037:Single-Blind Method
D000701:Analgesics, Opioid; D000779:Anesthetics, Local; D006993:Hypnotics and Sedatives; D008012:Lidocaine; D008874:Midazolam; D005283:Fentanyl; D004837:Epinephrine