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Anaesthesist 2002 Aug;51(8):644-9
Abteilung fur Anasthesiologie, Kliniken der Stadt Koln, Krankenhaus Merheim, Germany. drrainermueller@aol.com
The control of the neuromuscular blockade is part of the standard monitoring in general anaesthesia. However, the degree of blocking is affected by different disorders. We describe the neuromuscular monitoring in four patients suffering from central hemiplegia by stimulation of the ulnar nerve simultaneously on the paretic and the normal side. After application of non-depolarising muscle relaxants (Atracurium, Mivacurium, Rocuronium, Vecuronium) a resistance of the paretic extremity against the relaxant used was shown in all cases. A possible explanation for this observation is the spreading out of abnormal acetylcholine receptors over the surface of denervated muscle cells which could lead to a false estimation of the depth of the neuromuscular blockade. Therefore, in the clinical practice, neuromuscular monitoring must always be carried out on the normal extremity of the patient.
PMID: 12391524, UI: 22277806
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Anaesthesist 2002 Aug;51(8):634-9
Klinik fur Anasthesiologie, Intensivmedizin und Schmerztherapie, Johann Wolfgang Goethe-Universitat Frankfurt, Germany. G.Neidhart@em.uni-frankfurt.de
INTRODUCTION. Adequate preoxygenation of patients before onset of apnea for orotracheal intubation is of major importance in general anaesthesia. Various preoxygenation techniques are available but a face mask providing an oxygen supply via the circle absorber system of a mechanical respirator is most frequently used. Recently, a new device for preoxygenation - the NasOral((R)) system - has become available. The aim of the present study was to compare the efficacy of intrapulmonary oxygen storage with either the NasOral((R)) device or the standard face mask. METHODS. After informed and written consent and ethics committee approval was obtained, 40 elective patients (ASA I and II) undergoing surgical procedures of the neck and mouth area, were enrolled in this randomized, prospective study. In group A ( n=20), preoxygenation was performed using the NasOral((R)) system. Patients inhaled 100% oxygen through the nose and exhaled orally through unidirectional valves. In group B ( n=20), a conventional face mask with an O(2) flow of 15 l/min and an open airway pressure release valve was used for preoxygenation. In both groups preoxygenation lasted for 2.5 min. Induction of general anaesthesia was performed in a standardized manner. After intubation patients were not ventilated until the O(2) saturation in pulse oximetry (psaO(2)) dropped to 95%. This time of apnea was recorded in both groups and we determined the hemoglobin concentration (cHb) after beginning of ventilation. RESULTS. There were no significant differences with regard to demographic data and cHb. Time of apnea leading to a O(2) saturation of 95% was 6.0+/-2.1 min in group A and 6.3+/-2.1 min in group B (mean+/-SD, p>0.05). CONCLUSIONS. Both the NasOral((R)) system and the face mask are effective for intrapulmonary oxygen storage. In both systems the O(2) flow has to be adequately high and the masks have to be held tightly in order to avoid any contamination of the inhaled oxygen with nitrogen. Due to its unidirectional flow, the NasOral((R)) system additionally requires the patient to be cooperative. As the NasOral((R)) system is more expensive and has no clinical advantages without apneic oxygenation, we prefer the standard face mask for patient preoxygenation.
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PMID: 12391522, UI: 22277804
Anaesthesist 2002 Aug;51(8):625-33
Abteilung Anaesthesiologie, Intensivmedizin, Schmerztherapie, Universitatsklinikum Giessen, Germany.
BACKGROUND. The NICO(2) monitor determines "pulmonary capillary blood flow" (Qpc) and cardiac output (Qt) using the "partial CO(2) rebreathing technique". The agreement between NICO(2) and thermodilution (TD) cardiac output was compared before and after cardiac surgery with cardiopulmonary bypass (CBP). In addition, the possibility of calculating the intrapulmonary shunt fraction (Qs/Qt) by combining data from the NICO(2) monitor and the TD was investigated. METHODS. In 32 patients measurements were made following induction of anesthesia ("pre-CBP"), 30 min after weaning from CBP ("post-CBP"), and 6-8 h after surgery ("post-OP"). Qt was determined by the NICO(2) monitor and TD, Qpc by the NICO(2) monitor, and Qs/Qt(O(2)) from the standard formula. An intrapulmonary shunt was calculated using Qpc(NICO(2)) and Qt(TD) according to the equation Qs/Qt=1-Qpc/Qt. Bland-Altman and regression analysis techniques were used for statistical evaluation. RESULTS. "Pre-CBP" there was a good agreement between Qt(NICO(2)) and Qt(TD) with both a bias and precision of -0.13+/-0.46 l/min and a correlation of r=0.88+/-0.47 ( p<0.001). In contrast, "post-CBP" and "post-OP" there was a lack of agreement for Qt (bias and precision: 0.97+/-1.05 l/min and -0.33+/-0.8 l/min, respectively). Regarding the shunt calculations no significant correlations between methods could be found. CONCLUSION. Cardiac output measurement by the NICO(2) monitor agree well with TD under steady-state conditions but after CBP the agreement was too small. Combining Qpc(NICO(2)) and Qt(TD) does not offer a reliable possibility for calculating intrapulmonary shunt.
PMID: 12391521, UI: 22277803
Can J Anaesth 2002 Dec;49(10):1064-9
Department of Anesthesia, and Clinical Research Support Unit, British Columbia's Children's Hospital and the University of British Columbia, Vancouver, British Columbia, Canada.
[Medline record in process]
PURPOSE: To evaluate the incidence of pain on injection in children during anesthetic induction with a 3:1.2 volume admixture of 1% propofol and 2.5% thiopentone (P/T) compared to a 10:1 volume admixture of 1% propofol and 2% lidocaine (P/L). METHODS: After Ethics Committee approval and informed written parental consent, 127 children, aged one to ten years were studied and randomized into two groups; Group P/L received an induction with 5 mg*kg(-1) of 1% propofol and 1 mg*kg(-1) of lidocaine, Group P/T with 3 mg*kg(-1) of 1% propofol and 3 mg*kg(-1) of 2.5% thiopentone in a standardized fashion. A single, blinded observer scored pain behaviour defined as a motor response of the arm, a verbal complaint of pain, cry and/or one of three standardized facial expressions of pain. RESULTS: The incidence of pain was 14% in the P/T group, compared to 35% in the P/L group (chi(2)(1) = 7.5, P = 0.006). Motor response was the most frequent pain response in the P/L group (68%). CONCLUSION: The P/T admixture is a practical and efficacious alternative to P/L for reducing pain on induction in children. Further work to evaluate the optimum proportions and possible adverse effects of this admixture should be done.
PMID: 12477680, UI: 22365556
Can J Anaesth 2002 Dec;49(10):1057-60
Department of Anesthesia, BC Women's Hospital, Vancouver, British Columbia, Canada.
PURPOSE: To discuss the possible ramifications of neuraxial analgesia and anesthesia in women with tattoos involving their midline lumbar area. Clinical findings: Recently the authors have received requests for epidural anesthesia in three women with tattoos over the midline of their lumbar spine. In one patient the tattoo covered her entire back. In the other two, it was possible to locate a lumbar interspace that did not have tattoo pigment in the overlying skin. All three women received uneventful epidural analgesia. A Medline and EMBASE search for relevant publications using the keywords: epidural, spinal, tattoos, tattooing, complications did not find any reports of complications from inserting a needle through a tattoo. As none were found, the literature on tattoos and on coring with neuraxial anesthesia was reviewed to see if neuraxial anesthesia might be problematic if the needle passed through the tattoo. Coring is a complication of neuraxial anesthesia that may lead to epidermoid tumours in the subarachnoid space. Theoretically, a pigment-containing tissue core from a tattoo could be deposited into the epidural, subdural or subarachnoid spaces, leading to later neurological complications. CONCLUSIONS: There is no information in the literature about possible risks from inserting needles through tattoos during the performance of neuraxial anesthesia. This report discusses the possible implications.
PMID: 12477678, UI: 22365554
Can J Anaesth 2002 Dec;49(10):1040-3
Department of Anesthesia, and Biostatistics, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India.
PURPOSE: One hundred percent O(2) is used routinely for preoxygenation and induction of anesthesia. The higher the O(2) concentration the faster is the development of atelectasis, an important cause of impaired pulmonary gas exchange during general anesthesia (GA). We evaluated the effect of ventilation with 0.4 FIO(2) in air, 0.4 FIO(2) in N(2)O and 100% O(2) following intubation on the development of impaired gas exchange. METHODS: Twenty-seven patients aged 18-40 yr, undergoing elective laparoscopic cholecystectomy were administered 100% O(2) for preoxygenation (three minutes) and ventilation by mask (two minutes). Following intubation these patients were randomly divided into three groups of nine each and ventilated either with 0.4 FIO(2) in air, 0.4 FIO(2) in N(2)O or 100% O(2). Arterial blood gases were obtained before preoxygenation and 30 min following intubation for PaO(2) analysis. Subsequently PaO(2)/FIO(2) ratios were calculated. Results were analyzed with Student's t test and one-way ANOVA. P value of # 0.05 was considered significant. RESULTS: Ventilation of the lungs with O(2) in air (FIO(2) 0.4) significantly improved the PaO(2)/FIO(2) ratio from baseline, while 0.4 FIO(2) in N(2)O or 100% O(2) worsened the ratio (558 +/- 47 vs 472 +/- 28, 365 +/- 34 vs 472 +/- 22 and 351 +/- 23 vs 477 +/- 28 respectively; P < 0.05). CONCLUSION: Ventilation of lungs with O(2) in air (FIO(2) 0.4) improves gas exchange in young healthy patients during GA.
PMID: 12477674, UI: 22365550
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