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Anaesth Intensive Care 2002 Aug;30(4):532
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PMID: 12180598, UI: 22167909
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Anaesth Intensive Care 2002 Aug;30(4):505-6
PMID: 12180596, UI: 22167907
Anaesth Intensive Care 2002 Aug;30(4):502-4
Department of Anaesthesia, Vila Central Hospital, Port Vila, Vanuatu.
The successful management of tracheal stenosis requires compromise between the competing interests of the surgical and anaesthetic teams and the resources available. A seven-year-old girl with marked tracheal stenosis was successfully managed spontaneously breathing via an open trachea and a laryngeal mask. Anaesthesia was maintained by propofol infusion. When the trachea was opened, supplemental oxygen was administered via a modified cholangiocatheter placed into the distal segment. At no point was the trachea intubated.
PMID: 12180595, UI: 22167906
Anaesth Intensive Care 2002 Aug;30(4):499-501
Department of Thoracic Medicine, St Vincent's Hospital, Sydney, NSW, Australia.
Acute respiratory complications of an interscalene brachial plexus block include ipsilateral phrenic nerve and recurrent laryngeal nerve palsies. A 71-year-old woman who had undergone a total thyroidectomy for papillary carcinoma 35 years ago was administered a right interscalene brachial plexus block for a shoulder hemi-arthroplasty. Subsequently she developed acute respiratory distress associated with marked stridor secondary to an acute right vocal cord palsy, which was superimposed on what was assumed to be a preexisting left-sided vocal cord palsy. On extubation the patient was noted to develop stridor again necessitating reintubation and tracheostomy was performed two weeks later. The vocal cord palsies failed to resolve over the subsequent 18-month follow-up. We describe this case to highlight the significant risk of this procedure in patients with preexisting or suspected contralateral vocal cord palsy.
PMID: 12180594, UI: 22167905
Anaesth Intensive Care 2002 Aug;30(4):495-8
Department of Anaesthesia and Intensive Care, All India Institute of Medical Sciences, Ansari Nagar, New Delhi.
A five-year-old child with severe arthrogryposis multiplex congenita and malnutrition underwent surgery for chronic osteomyelitis of the head of the left humerus. The child had typical features of arthrogryposis multiplex congenita, including a difficult airway. Propofol was used for induction and maintenance. Spontaneous respiration was maintained with a nasal airway. Analgesia was provided with an interscalene brachial plexus block placed using a nerve stimulator. No opioid was given. The child had an uneventful recovery with good postoperative analgesia. The anaesthetic implications of arthrogryposis multiplex congenita are discussed.
PMID: 12180593, UI: 22167904
Anaesth Intensive Care 2002 Aug;30(4):484-6
Department of Anaesthesia, Mercy Hospital for Women, East Melbourne, Victoria.
We present the first reported case involving the peripartum anaesthetic management of dopamine beta-hydroxylase deficiency in a 22-year-old primigravida with high-grade placenta praevia. Elective caesarean section was performed at 36 weeks gestation with a combined spinal-epidural regional anaesthetic technique. Extensive preparation was undertaken to manage the consequences of obstetric haemorrhage and consideration given to potential pharmacological sensitivities suspected to exist in patients with this rare disorder affecting sympathetic nervous system function. An uncomplicated caesarean section was performed from which the patient recovered well to be discharged home with a healthy baby.
PMID: 12180590, UI: 22167901
Anaesth Intensive Care 2002 Aug;30(4):467-71
Department of Anaesthesia, Alexandra Hospital, Singapore.
A patient with advanced bronchiectasis, severe pulmonary hypertension complicated by cor pulmonale and a right-to-left shunt at atrial level presented for sigmoid colectomy. We outline the potential perioperative problems of this situation, discuss the perioperative risks and describe our clinical approach. A total intravenous anaesthetic technique using midazolam, fentanyl, ketamine and rocuronium was used to minimize changes in pulmonary and systemic vascular resistance and not induce bronchospasm. Preoperative nebulized salbutamol and ipratroprium were given to prevent bronchospasm and adrenaline and noradrenaline were infused to maintain cardiac output and the balance between systemic and pulmonary vascular resistance.
PMID: 12180586, UI: 22167897
Anaesth Intensive Care 2002 Aug;30(4):442-8
Department of Anaesthesiology, Queen Mary Hospital, Hong Kong.
Neurolytic celiac plexus block is a recognised treatment for visceral abdominal pain due to malignancy. The need for a diagnostic celiac plexus block prior to neurolytic blockade is of questionable value, as it may not predict a positive response and may incorrectly predict a lack of response. Our objective is to evaluate the efficacy of diagnostic celiac plexus block. The records of 59 patients treated with celiac plexus block during 1994-2000 were retrospectively reviewed. Diagnostic block was performed on 32 patients prior to the decision for subsequent neurolytic block (Group 1). Another 27 patients were directly treated with a neurolytic celiac plexus block (Group 2). Response of Group 1 to diagnostic and neurolytic blocks was compared. Data from Group 2 was used to project the response of Group 1 should those patients with negative response to diagnostic block proceeded to neurolytic block. A two-by-two table was then constructed. The diagnostic celiac plexus block predicted a positive response with a sensitivity of 93% and a specificity of 37%. The positive predictive value was 85% and the negative predictive value was 58%. The estimated "number needed to test" before a "true" nonrespondent to lytic block to be detected was 16.7. Therefore, a positive response to diagnostic block correlates positively with neurolytic celiac plexus block for abdominal visceral pain due to malignancy. However, diagnostic block is a poor predictor when the response is negative. Hence, its clinical role is questionable and may not be warranted for patients with terminal malignancy.
PMID: 12180582, UI: 22167893
Anaesth Intensive Care 2002 Aug;30(4):433-7
Department of Anaesthesiology and Intensive Care, All India Institute of Medical Sciences, New Delhi.
We studied remifentanil and propofol for analgesia and sedation during the placement of an ophthalmic block. Eighty ASA I or II patients undergoing elective cataract surgery under a retrobulbar block in a rural camp setting were included in the study. Patients were randomly divided into four groups and received different drug combinations as follows: Group I--remifentanil 1 microg/kg, Group II--remifentanil 0.5 microg/kg and propofol 0.5 mg/kg, Group III--remifentanil 1 microg/kg with propofol 0.5 mg/kg and Group IV--saline 0.1 ml/kg. Patients were observed for degree of movement, sedation, pain, recall and respiratory depression. No patient in the study groups reported pain or displayed movement whereas most of the patients in the control group had significant pain during the placement of the block. Also, seven (35%) patients in the control group showed significant movement which may have led to failure of block in two patients and retrobulbar haemorrhage in one patient. Incidence of significant respiratory depression was maximum in Group III patients (60%), followed by Group I (20%) and least in Group II (5%). All patients in the study groups remained cooperative and obeyed commands except four patients in group III (OAA/S-4). Postoperatively, other than the control group, recall was maximum in Group I (55%) and least in Group II (5%). Hence, a combination of remifentanil 0.5 microg/kg with propofol 0.5 mg/kg as a bolus was considered to provide excellent relief of pain and anxiety with least adverse effects for the placement of ophthalmic blocks.
PMID: 12180580, UI: 22167891
Anaesthesist 2002 Oct;51(10):868-81
PMID: 12555773, UI: 22443029
Anesthesiology 2003 Feb;98(2):577-9
*Staff Anesthesiologist, Fukaya Red Cross Hospital, Fukaya, Japan. dagger Staff Anesthesiologist, double dagger Assistant Professor, section sign Professor and Chair, Department of Anesthesiology & Reanimatology, Gunma University School of Medicine.
[Medline record in process]
PMID: 12552221, UI: 22437804
Anesthesiology 2003 Feb;98(2):571-3
*Assistenzarztin, Klinik fur Anasthesiologie und Intensivmedizin, dagger Oberarzt, Klinik fur Anasthesiologie und Intensivmedizin, double dagger Professor of Anesthesiology and Intensive Care Therapy, Chairman.
PMID: 12552218, UI: 22437801
Anesthesiology 2003 Feb;98(2):548-64
*Associate Professor, dagger Research Assistant.
PMID: 12552216, UI: 22437799
Anesthesiology 2003 Feb;98(2):530-47
*Professor and Chief of Staff. dagger Consultant.
PMID: 12552215, UI: 22437798
Anesthesiology 2003 Feb;98(2):521-529
*Instructor, Department of Anesthesia, section sign Associate Professor, Department of Radiology, parallel Professor, Departments of Anesthesia and Pediatrics, Harvard Medical School. dagger Postdoctoral Fellow, Department of Radiology, University Medical Center Nijmegen, Nijmegen, The Netherlands. double dagger Laboratory Manager, Kresge Laboratory, Department of Radiology, Children's Hospital.
[Record supplied by publisher]
BACKGROUND Postsurgical wound infiltration with the -methyl-d-aspartate receptor antagonist ketamine and bupivacaine can significantly prolong the duration of local anesthesia. One possible mechanism for this effect is that increased glutamate concentrations, caused by tissue damage, sensitize nociceptive primary afferent fibers through activation of peripheral excitatory amino acid receptors.METHODS The effect of intramuscular injection of hyper-tonic glutamate (1,000 mm), dextrose (1,400 mm), glutamate (1,000 mm) with the broad spectrum excitatory amino acid receptor antagonist kynurenate (100 mm), or isotonic saline (155 mm) on the duration of masseter muscle afferent fiber blockade after lidocaine (37 mm [1%], 10 &mgr;l) infiltration, on muscle edema formation and on muscle blood flow was examined.RESULTS Injection of either glutamate or dextrose significantly shortened the duration of lidocaine blocks compared with isotonic saline; however, block duration was significantly shorter after glutamate than after dextrose. Injection of glutamate, but not isotonic saline, dextrose, or glutamate with kynurenate, significantly decreased the mechanical threshold of muscle afferent fibers. Injection of glutamate, dextrose, or glutamate with kynurenate produced equivalent large, long-lasting (> 60 min) edemas with high initial peak extracellular water content. Peak extracellular water decreased more rapidly when kynurenate was coinjected with glutamate. Both glutamate and dextrose significantly increased muscle blood flow for 30 min after injection. Glutamate-induced increases in blood flow were attenuated by kynurenate.CONCLUSIONS These results suggest that shortened lidocaine block durations observed after glutamate injection into the masseter muscle result from sensitization of afferent fibers as well as increases of peak extracellular water content and blood flow in masseter muscle. These effects of glutamate are mediated in part through activation of peripheral excitatory amino acid receptors.
PMID: 12552214
Anesthesiology 2003 Feb;98(2):511-515
*Clinical Fellow, dagger Research Fellow, double dagger Professor of Anesthesia.
BACKGROUND The ability of patients to walk without assistance after spinal anesthesia is a determining factor in the time to discharge following ambulatory surgery. The authors compared clinical markers of gross motor recovery with objective data of functional balance after spinal anesthesia.METHODS Twenty-two male patients with American Society of Anesthesiology physical status I or II who were scheduled for perineal surgery were studied during recovery from spinal anesthesia to compare the predictive accuracy of clinical markers of ambulatory readiness (, full knee flexion and extension) with that of an objective method of measurement focused on functional balance. Lumbar puncture was performed at the L2-L3 or L3-L4 interspace using a 25-gauge Whitacre needle, with patients in the sitting position. A 3-ml mixture of 5 mg bupivacaine (heavy) and 10 &mgr;g fentanyl was injected. Block regression and restoration of motor function were assessed and recorded. Functional balance was measured using a computerized force platform method.RESULTS The majority of patients maintained motor function and proprioception sensation at the onset of surgical anesthesia, as indicated by performance on clinical tests of function: 96% were able to perform the straight leg increase; 82, 77, and 91%, respectively, were able to perform full knee flexion and extension, perform heel-to-shin maneuvers, and identify joint position in the supine position. Postoperatively, clinical return of motor function occurred much earlier than recovery of functional balance. At 60 min after onset of spinal anesthesia, 22 patients (100%) had recovered sensory and gross motor function, but only 36% could stand, and 8% could walk without assistance ( < 0.01). At 150-180 min after onset, 96-100% of patients achieved the levels of functional balance that permitted adequate ambulation.CONCLUSIONS The results suggest that the recovery time to unassisted ambulation is longer than has been assumed, and that the standard clinical markers of gross motor function are poor predictors of functional balance following ambulatory surgery.
PMID: 12552212
Anesthesiology 2003 Feb;98(2):499-510
*Chief Resident, Department of Anesthesia, Health Sciences Center, University of Manitoba. dagger Associate Professor, double dagger Professor, Department of Anesthesiology, Duke University Medical Center. section sign Associate Professor, Departments of Anesthesia, Internal Medicine, and Surgery, University of Manitoba. parallel See Appendix for members of the Winnipeg High-Spinal Anesthesia Group.
BACKGROUND This double-blind, randomized, controlled trial examined the effect of high-dose intrathecal bupivacaine in combination with general anesthesia on atrial beta-adrenergic receptor function, the stress response, and hemodynamics during coronary artery bypass graft surgery.METHODS Thirty-eight patients were randomized to either control (n = 19) or intrathecal bupivacaine (ITB) groups (n = 19). Patients in the ITB group received 37.5 mg intrathecal hyperbaric bupivacaine before induction of general anesthesia. Control patients received an injection of local anesthetic into the skin and subcutaneous tissues (sham spinal). Comparisons were made between groups with respect to atrial receptor desensitization and down-regulation, in addition to circulating catecholamines and hemodynamics.RESULTS In patients with cardiopulmonary bypass (CPB) times in excess of 1 h, the ITB group had significantly less atrial beta-receptor dysfunction, as measured by maximal isproteronol, 50% maximal isoproterenol, sodium fluoride-stimulated activity, and zinterol stimulation assays of adenylyl cyclase activity ( </= 0.02) and beta-adrenergic receptor density ( = 0.02). Serum epinephrine, norepinephrine, and cortisol concentrations were significantly lower in the ITB group, independent of CPB times ( < 0.0001, < 0.001, and < 0.05, respectively). ITB patients had a higher cardiac index and a lower pulmonary vascular resistance index in the post-CPB time period ( < 0.01 and < 0.05, respectively). In the pre-CPB period, mean arterial pressure and systemic vascular resistance index were significantly lower in the ITB group.CONCLUSIONS High-dose intrathecal bupivacaine, when combined with general anesthesia, resulted in less beta-receptor dysfunction and a lower stress response during coronary artery bypass graft surgery.
PMID: 12552211
Anesthesiology 2003 Feb;98(2):437-448
*The Wenner-Gren Institute, The Arrhenius Laboratories F3, Stockholm University; permanent affiliation: Consultant Anesthesiologist, Department of Anesthesiology and Intensive Care, Lund University Hospital. dagger Professor of Anesthesia, Director of Research, The Karolinska Hospital. double dagger Professor of Physiology and Director, section sign Professor of Physiology, The Wenner-Gren Institute, The Arrhenius Laboratories F3, Stockholm University.
BACKGROUND This investigation examined the possibility that the inhibitory effect of halothane on nonshivering thermogenesis (heat production) in brown adipocytes is not a universal effect of all anesthetic agents but related to the type of anesthetic.METHODS Brown adipocytes from hamster were isolated with a collagenase digestion method and incubated with anesthetic agents. The rate of oxygen consumption was measured with an oxygen electrode. The effect of clinically relevant (and higher) doses of anesthetics of different classes on basal and norepinephrine-induced thermogenesis (oxygen consumption) was tested.RESULTS Two distinct groups of anesthetics could be distinguished: thermogenesis inhibitors and noninhibitors. Thermogenesis inhibitors include volatile anesthetics such as halothane (IC, 1.1 mm), ether (IC, 20 mm), and chloroform (IC, 2.2 mm) (nominal concentrations), but also tribromoethanol (IC, 0.6 mm), all inducing inhibition of norepinephrine-induced thermogenesis without affecting the EC for norepinephrine. Thermogenesis noninhibitors include the nonvolatile anesthetics pentobarbital, propofol, ketamine, and urethane, the inhalation anesthetic nitrous oxide, and, notably, also the volatile nonanesthetics (nonimmobilizers) 1,2-dichlorohexafluorocyclobutane and 2,3-dichlorooctafluorobutane; none of these compounds had any effect on norepinephrine-induced thermogenesis at any concentration tested.(50) (50) (50) (50) (50)CONCLUSIONS There are two distinct classes of anesthetics with regard to effects on thermogenesis, thermogenesis inhibitors and thermogenesis noninhibitors. The results are important for the interpretation of studies in thermal biology in general; specifically, they indicate that conclusions concerning regulation of nonshivering thermogenesis during anesthesia depend on the type of anesthetic used. Of clinical importance is that the volatile anesthetics are inhibitory for nonshivering thermogenesis and thus for an alternative heat production when myorelaxants prevent shivering. As the distinction between thermogenesis inhibitors and thermogenesis noninhibitors corresponds to the distinction between volatile and nonvolatile anesthetics, it may be related to the mode of action of the volatile anesthetics.
PMID: 12552204
Anesthesiology 2003 Feb;98(2):329-336
*Staff Anesthesiologist, dagger Assistant Professor, Department of Anesthesia and Neurosurgery, Aarhus University Hospital. double dagger Staff Anesthesiologist, section sign Staff Neurosurgeon, Rigshospitalet, Kobenhavn, Denmark. parallel Staff Neurosurgeon, #Staff Anesthesiologist, **Assistant Professor in Anesthesiology, Glostrup Hospital, Glostrup, Denmark.
BACKGROUND A critical point during craniotomy is opening of dura, where a high intracranial pressure (ICP) results in swelling of cerebral tissue. Controlled studies concerning ICP, degree of dural tension, and degree of cerebral swelling are therefore warranted.METHODS In an open-label study, 117 patients with supratentorial cerebral tumors were randomized to propofol-fentanyl (group 1), isoflurane-fentanyl (group 2), or sevoflurane-fentanyl anesthesia (group 3). Normo- to moderate hypocapnia was applied, with a target level of arterial carbon dioxid tension of 30-40 mmHg. Mean arterial blood pressure was stabilized with intravenous ephedrine (2.5-5 mg) if necessary. Subdural ICP, mean arterial blood pressure, cerebral perfusion pressure (CPP), arteriovenous oxygen difference (AVDo ), internal jugular vein oxygen saturation were monitored before and after a 10-min period of hyperventilation, and the carbon dioxide reactivity was calculated. Furthermore, the tension of dura before and during hyperventilation and the degree of cerebral swelling during hyperventilation and after opening of the dura were estimated by the neurosurgeon.(2)RESULTS No differences were found between groups with regard to demographics, neuroradiologic examination, positioning of the head, and time to ICP measurement. Before and during hyperventilation, ICP was significantly lower and mean arterial blood pressure and CPP significantly higher in group 1 compared with groups 2 and 3 ( < 0.05). The tension of dura before and during hyperventilation was significantly lower in group 1 compared with group2 ( < 0.05), but not significantly different from group 3. In group 1, cerebral swelling after opening of dura was significantly lower compared with groups 2 and 3 ( < 0.05). Furthermore, AVDo was significantly higher and jugular vein oxygen saturation and carbon dioxide reactivity were significantly lower in group 1 compared with groups 2 and 3 ( < 0.05). No significant differences with regard to ICP, CPP, AVDo, carbon dioxide reactivity, and jugular vein oxygen saturation were found between patients anesthetized with isoflurane and sevoflurane.(2) (2)CONCLUSIONS The study indicates that before as well as during hyperventilation, subdural ICP and AVDo are lower and CPP higher in propofol-anesthetized patients compared with patients anesthetized with isoflurane or sevoflurane. These findings were associated with less tendency for cerebral swelling after opening of dura in the propofol group. The carbon dioxide reactivity in patients anesthetized with isoflurane and sevoflurane was significantly higher than in the propofol group. The differences in subdural ICP between the groups are presumed to be caused by differences in the degree of vasoconstriction elicited by the anesthetic agents, but autoregulatory mechanisms caused by differences in CPP cannot be excluded.(2)
PMID: 12552189
Anesthesiology 2003 Feb;98(2):5A-6A
PMID: 12552181, UI: 22437764
Ann Fr Anesth Reanim 2002 Nov;21(9):f155-6
d.boisson-bertrand@chu-nancy.fr
PMID: 12494820, UI: 22383057
Ann Fr Anesth Reanim 2002 Nov;21(9):f151-4
Service d'anesthesie-reanimation, Universite Paris VII, hopital Beaujon, 92118 Clichy. franck.lagneau@bjn.ap-hop-paris.fr
PMID: 12494819, UI: 22383056
Ann Fr Anesth Reanim 2002 Nov;21(9):753
PMID: 12494815, UI: 22383052
Ann Fr Anesth Reanim 2002 Nov;21(9):734-6
Departement d'anesthesie-reanimation, consultation de la douleur chronique, 02001 Laon, France.
We report a case of idiopathic brachial nevralgia of the right shoulder in a 30-year-old female, after caesarean section, under spinal anaesthesia. Two days after surgery, intense cervical pain appeared on the second day, associated with rapid collapse of muscular shoulder belt. Full recovery occurred in four months.
PMID: 12494809, UI: 22383046
Ann Fr Anesth Reanim 2002 Nov;21(9):725-7
Departement d'anesthesie-reanimation, hopital d'instruction des armees Sainte-Anne, 83500 Toulon-Naval, France. bruno.palmier@free.fr
We report a case of pupilloplasty under peribulbar anaesthesia complicated by a brainstem anaesthesia requiring tracheal intubation and mechanical ventilation. Immediate outcome was good. We discuss the different mechanisms of this complication. The subarachnoidal (intrathecal) injection of local anaesthesic seems to be the most probable cause. The use of short needles should theoretically decrease the risk. Despite all these precautions, peribulbar anaesthesia should not be considered as an ordinary procedure.
PMID: 12494806, UI: 22383043
Ann Fr Anesth Reanim 2002 Nov;21(9):713-24
Service d'anesthesie-reanimation, CHU de Liege, domaine du Sart Tilman, B-4000 Liege, Belgique. msenard@chu.ulg.ac.be
OBJECTIVES: To describe pharmacology and toxicology of ropivacaine. To assess the clinical efficacy of ropivacaine when used for postoperative epidural analgesia and to provide recommendations for clinical practice. DATA SOURCES: Search in the Medline data base of original articles in French and English published since 1995, using the following key words: ropivacaine, postoperative analgesia, epidural, caudal block. STUDY SELECTION: Prospective randomised studies in adults and children were selected. Letters to editors and editorials were excluded. DATA EXTRACTION: Articles have been analyzed: to determine the dose of ropivacaine required for postoperative epidural analgesia, to assess the benefits of combination of epidural ropivacaine and additives (opioids or other), to compare epidural ropivacaine and bupivacaine and to assess the use of ropivacaine via caudal route for paediatric postoperative analgesia. DATA SYNTHESIS: 20 mg h-1 of ropivacaine is required to provide effective analgesia. This dose produces a motor block in a significant number of patients. Combination with an opioid allows for a reduction in ropivacaine requirement and subsequently in the incidence of motor blockade. In adults, equipotency ratio of ropivacaine and bupivacaine varies between 1.5/1 and 1/1 depending upon the concentration used. At equipotent doses, early postoperative mobilisation is facilitated with ropivacaine. In case of paediatric caudal analgesia, this ratio is close to 1. CONCLUSIONS: Epidural ropivacaine combined with opioid provide good postoperative pain relief. Reduction in the incidence of motor blockade and safe toxicological profile make this local anaesthetic a suitable alternative of bupivacaine for postoperative epidural analgesia.
PMID: 12494805, UI: 22383042
Ann Fr Anesth Reanim 2002 Nov;21(9):710-2
Departement d'anesthesie-reanimation, Hotel-Dieu de France, Beyrouth, Liban.
OBJECTIVE: The aim of this study was to evaluate the effectiveness of bilateral ilioinguinal-iliohypogastric nerve blocks for pain relief following ambulatory bilateral varicocelectomy. STUDY DESIGN: Prospective and randomised. PATIENTS AND METHODS: Sixty adult men scheduled for bilateral varicocelectomy were included in this prospective study. All patients had a standardised general anesthesia. After surgical procedures, patients were randomized into two groups: patients in group I received a bilateral ilioinguinal nerve block with 15 ml x 2 of 0.25% bupivacaine; patients in group II received subcutaneously 1 mg kg-1 of tramadol. Visual analogue pain scores at rest and during mobilisation were recorded at 5 min and 1, 3, 5 postoperative hours. The side effects of analgesia and amounts of rescue analgesics were recorded. RESULTS: Pain scores at rest and during mobilisation, the incidence of postoperative nausea and vomiting and additional analgesics requirement were significantly reduced in group I. There was no complication. CONCLUSION: Ilioinguinal nerve block is effective in controlling pain after bilateral varicocelectomy in ambulatory surgery.
PMID: 12494804, UI: 22383041
Ann Fr Anesth Reanim 2002 Nov;21(9):689-91
PMID: 12494800, UI: 22383037
Can J Anaesth 2003 Feb;50(2):166-71
Department of Anaesthesia, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
PURPOSE: Maintenance of cerebrovascular reactivity to CO(2) (CCO(2)R) is important during neurosurgical anesthesia. This study was designed to determine the effect of different desflurane concentrations on CCO(2)R in children. METHODS: Children undergoing urological surgery were enrolled. Anesthesia was induced with sevoflurane in air/oxygen. After intubation, sevoflurane was switched to desflurane. Analgesia was provided with an epidural neuraxial block. Mechanical ventilation was adjusted to an initial EtCO(2) of 30 mmHg. Exogenous CO(2) was used to achieve an EtCO(2) of 40 and 50 mmHg. Patients were randomized to the sequence of desflurane concentration (1.0 and 1.5 MAC) and the EtCO(2). Transcranial Doppler was used to measure middle cerebral artery blood flow velocity (Vmca). Five minutes were allowed to reach steady state after each change in EtCO(2) and 15 min after changing the desflurane concentration. RESULTS: Sixteen patients were studied. The mean age and weight were 3.5 +/- 1.5 yr and 14.4 +/- 3.1 kg, respectively. Mean arterial pressure remained stable throughout the study, while at an EtCO(2) of 50 mmHg, heart rate decreased at both desflurane concentrations (P < 0.05). At 1.0 MAC, Vmca increased from 30 to 40 mmHg (P < 0.05), but not from 40 to 50 mmHg EtCO(2). At 1.5 MAC, Vmca increased between 30 and 50 mmHg (P < 0.05). CONCLUSION: CCO(2)R is preserved during hypocapnia in children anesthetized with 1.0 MAC, but not with 1.5 MAC desflurane. The lack of further increase in Vmca at higher EtCO(2) concentrations implies that desflurane may cause significant cerebral vasodilatation in children. This may have important implications in children with reduced intracranial compliance.
PMID: 12560309, UI: 22446572
Can J Anaesth 2003 Feb;50(2):161-5
Department of Anesthesia, and the Department of Obstetrics & Gynecology McGill University Health Centre Royal Victoria Hospital Montreal Quebec Canada.
PURPOSE: To describe the anesthetic management and clinical course of a patient with peripartum cardiomyopathy. We highlight the frequent occurrence of thromboembolic morbidity in this group of parturients, emphasizing the need for early consideration of prophylactic anticoagulation. Clinical features: A 38-yr-old, diabetic, obese parturient was admitted with pulmonary edema and severe orthopnea at 31 weeks gestation. The respiratory rate was 44 breaths*min(-1), blood pressure 110/70 mmHg, pulse 120 beats*min(-1) and rales were heard in both lung fields. The diagnosis of peripartum cardiomyopathy was made based on sinus tachycardia with no evidence of ischemia on the electrocardiogram, and global left ventricular hypokinesis with an ejection fraction of 40-45% noted on transthoracic echocardiography. Cesarean delivery was planned to improve maternal respiratory status and hemodynamics. General anesthesia with invasive monitoring was planned, and surgery and anesthesia proceeded uneventfully. Less than 24 hr postoperatively, she sustained a thrombotic cerebral infarct leaving her hemiparetic and dysarthric. Subsequent investigations revealed a thrombophilic state due to elevated anticardiolipin antibody. CONCLUSION: General anesthesia is an acceptable option in parturients with heart failure secondary to cardiomyopathy. Thromboembolic complications are common, and early consideration should be given to prophylactic anticoagulation.
PMID: 12560308, UI: 22446571
Can J Anaesth 2003 Feb;50(2):159-60
San Diego, California.
PMID: 12560307, UI: 22446570
Can J Anaesth 2003 Feb;50(2):153-8
Departments of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut, and The University Of Arkansas For Medical Sciences, Little Rock, Arkansas, USA.
PURPOSE: Peripheral opioid receptors may result in antinociceptive effects when occupied by opioids. This study examined intradermally injected sufentanil (S), a highly lipid soluble opioid, administered with and without lidocaine (L), in a thermal pain model. METHODS: Nine volunteers were instructed on the method of magnitude estimation of pain before undergoing baseline testing with seven seconds thermal stimuli between 44 and 52 degrees C, delivered by a contact thermal stimulator at five cutaneous forearm sites. Then, four sites randomly received injections of equal volumes (0.1 mL) of either normal saline (NS), lidocaine 0.5% (L), sufentanil 0.75 micro g (S), lidocaine 0.5% plus sufentanil 0.75 micro g (L+S), and one site was not injected and served as reference (REF). Testing was repeated at six, 30, 60, 90, 120, and 150 min following injection. The pain elicited by each stimulus was normalized to the subject's response to the 50 degrees C stimulus at the REF site. RESULTS: Baseline testing showed small (P = ns) differences in pain scores. At six minutes, the lidocaine sites (L, L+S) had pain scores that were mean 83% (range 78-88%) lower than the other sites (P < 0.05), but there was no difference between the L and L+S sites or between the S and NS or REF sites. At 30 and 60 min these pain scores were mean 38% (29-44%) and 20% (8-30%) less than at the REF, NS, and S sites (P = ns). At 90 min and later times, the pain scores had returned to baseline. CONCLUSIONS: These results suggest that intradermal sufentanil alone has no analgesic effect. Further, in combination with lidocaine, sufentanil does neither potentiate nor prolong the analgesic effect of lidocaine.
PMID: 12560306, UI: 22446569
Can J Anaesth 2003 Feb;50(2):143-6
London, Ontario Toronto, Ontario.
PMID: 12560304, UI: 22446567
Can J Anaesth 2002 Jun-Jul;49(6):S36-49
Department of Pathology and Molecular Medicine, Department of Medicine, McMaster University, Hamilton Regional Laboratory Medicine Program, Hamilton Health Sciences, Hamilton, Ontario, Canada.
PURPOSE: All physicians who use heparin should be aware of immune heparin-induced thrombocytopenia (HIT), including anesthesiologists who may need to provide intraoperative anticoagulation for a patient who urgently requires cardiac or vascular surgery but who has acute HIT or a history of recent HIT. SOURCE: The literature dealing with HIT of relevance to anesthesiologists was reviewed, including studies of HIT antibody formation following intraoperative use of heparin; acute respiratory or cardiac arrest following i.v. bolus heparin indicating rapid-onset HIT; acute thrombocytopenia and thrombosis complicating intraoperative heparin use; circumstances in which it might be acceptable to administer heparin despite a previous history of immune HIT; and alternative anticoagulant approaches that can be used to manage cardiac or vascular surgery in a patient with acute or recent HIT. PRINCIPAL FINDINGS: Intraoperative exposure to heparin can trigger formation of HIT antibodies, and occasionally even lead to "delayed-onset" HIT. Acute respiratory or cardiac arrest following i.v. bolus heparin, or the abrupt occurrence of intraoperative "white clots," suggests a diagnosis of rapid-onset HIT, particularly if the patient recently received heparin. Several approaches are available to manage cardiac or vascular surgery in a patient with acute or recent HIT, so the treatment chosen depends upon local experience and monitoring capabilities. Several months after acute HIT, and particularly when HIT antibodies are no longer detectable, it may be acceptable to use heparin for intraoperative anticoagulation. CONCLUSION: HIT is an infrequent but important topic for anesthesiologists because of the urgency and complexity of the various associated management issues.
PMID: 12557413, UI: 22445604
Can J Anaesth 2002 Jun-Jul;49(6):S26-35
Departement d'anesthesie-reanimation, Centre Hospitalier Universitaire (CHU) Avicenne, Bobigny, France. cmsamama@invivo.edu
PURPOSE: Antiplatelet agents are administered to an increasing number of patients. Preoperative treatment with these agents represents a major problem for the anesthesiologist. The results of a French expert meeting on their perioperative management are reported. METHODS: Responses to questions formulated by the Organizing Committee were drafted by a group of experts and reviewed by a multidisciplinary. Reading Committee. Recommendations were classified (grade) according to the evidence level of the studies supporting them. PRINCIPAL FINDINGS: First, antiplatelet agents have a variable effect on hemostasis as far as bleeding risk is concerned. Aspirin and non-steroidal anti-inflammatory drugs (NSAIDs) increase intra- and postoperative bleeding moderately, but not transfusion requirements. Very few data are available on clopidogrel and ticlopidin. Anti-glycoprotein (GP) IIb/IIIa agents may increase bleeding when surgery is required in proximity with their administration. Second, the common practice of withdrawing antiplatelet agents is now challenged because an increased incidence of myocardial infarction has been reported in patients in whom treatment was interrupted. Third, aspirin should not be withdrawn for most vascular procedures and in several additional settings. When a definite increase in intraoperative bleeding is feared, or when surgical hemostasis is difficult, aspirin, clopidogrel or ticlopidine can be replaced by short-acting NSAIDS, given for a ten-day period and interrupted the day before surgery. Platelet transfusion should only be given when overt bleeding is observed. Postoperatively, antiplatelet treatment should be resumed immediately after surgery (first six hours). CONCLUSION: Anesthesiologists should be aware of the indications, potential complications and means of substitution of these agents.
PMID: 12557412, UI: 22445603
Can J Anaesth 2002 Jun-Jul;49(6):S5-10
Division of Angiology and Hemostasis, Department of Medicine, University Hospital of Geneva, Geneva, Switzerland. philippe.deMoerloose@hcuge.ch
PURPOSE: To describe two new antithrombotic agents (fondaparinux and ximelagatran), their mechanisms of action, the clinical studies available and some implications (regional anesthesia, monitoring and antidote) in anesthesia. SOURCE: Recently published articles on these two new drugs were reviewed. PRINCIPAL FINDINGS: These two drugs have several interesting properties. Both are of non animal origin, do not induce thrombocytopenia and do not require laboratory controls. In recent studies fondaparinux has shown a better efficacy than low molecular weight heparin in major orthopedic interventions. Ximelagatran, which can be given orally and is in phase III investigation, could replace vitamin K antagonist in the future. CONCLUSION: Anesthesiologists should be aware of these two new agents, one (fondaparinux) being now already registered in some countries.
PMID: 12557410, UI: 22445601
Can J Anaesth 2002 Jun-Jul;49(6):S4
Department of Anesthesiology, Centre hospitalier de l'universite de Montreal, Hopital Notre-Dame, 1560, rue Sherbrooke est, Montreal, Quebec H2L 4M1, Canada. jean-francois.hardy@umontreal.ca
PMID: 12557409, UI: 22445600
Can J Anaesth 2002 Dec;49(10):S21-6
Department of Anesthesiology, University of Western Ontario, London, Canada. j murkin@uwo.ca
PMID: 12546007, UI: 22433217
Eur J Anaesthesiol 2003 Jan;20(1):77-8
PMID: 12553396, UI: 22440428
Eur J Anaesthesiol 2003 Jan;20(1):61-4
Ege University, Department of Anaesthesiology and Reanimation, Faculty of Medicine, Bornova, Izmir, Turkey. elvanerhan@yahoo.com
BACKGROUND AND OBJECTIVE: We assessed the intraoperative haemodynamic responses and recovery profiles of total intravenous anaesthesia with remifentanil and alfentanil for outpatient surgery. METHODS: Patients in Group 1 (n = 20) received alfentanil 20 microg kg(-1) followed by 2 microg kg(-1) min(-1) intravenously; patients in Group 2 (n = 20) received remifentanil 1 microg kg(-1) followed by 0.5 microg kg(-1) min(-1) intravenously. Both groups then received propofol 2 mg kg(-1) followed by 9 mg kg(-1) h(-1) intravenously. Five minutes after skin incision, infusion rates were decreased, and at the end of surgery, all infusions were discontinued. Early recovery was assessed by the Aldrete score, whereas intermediate recovery was assessed with the postanaesthetic discharge scoring system (PADS). RESULTS: Perioperative arterial pressure was similar in both groups; heart rate was lower in Group 2 (P < 0.05). The times to spontaneous and adequate respiration, response to verbal commands, extubation and times for Aldrete score > or = 9 were shorter in Group 2 patients (P < 0.05). Pain scores were higher in Group 2 patients (P < 0.05). Overall times for postanaesthetic discharge scores > or = 9 were similar. CONCLUSIONS: Early recovery of patients after day surgery is significantly shorter after total intravenous anaesthesia with remifentanil compared with that with alfentanil but postoperative pain management must be planned ahead.
PMID: 12553390, UI: 22440422
Eur J Anaesthesiol 2003 Jan;20(1):26-30
University of Selcuk, Faculty of Medicine, Department of Anaesthesiology, Konya, Turkey. ireisli@hotmail.com
BACKGROUND AND OBJECTIVE: To compare, using prilocaine, the effects of continuous spinal anaesthesia (CSA) and continuous epidural anaesthesia (CEA) on haemodynamic stability as well as the quality of anaesthesia and recovery in patients undergoing transurethral resection of the prostate gland. METHODS: Thirty patients (>60 yr) were randomized into two groups. Prilocaine, 2% 40 mg, was given to patients in the CSA group, and prilocaine 1% 150mg was given to patients in the CEA group. Incremental doses were given if the level of sensory block was lower than T10 or if needed during surgery. RESULTS: There was a significant decrease in mean arterial pressure in Group CEA compared with Group CSA (P < 0.01). The decrease in heart rate in Group CSA occurred 10 min after the first local anaesthetic administration and continued through the operation (P < 0.05). The level of sensory anaesthesia was similar in both groups. The times to reach the level of T10 and the upper level of sensory blockade (Tmax) were 18.0 +/- 4.7 and 25.3 +/- 7.0 min in Groups CSA and CEA, respectively, and were significantly longer in Group CEA. The duration of anaesthesia was 76.8 +/- 4min and was shorter in Group CSA (P < 0.01). CONCLUSIONS: Spinal or epidural anaesthesia administered continuously was reliable in elderly patients undergoing transurethral resection of the prostate. Continuous spinal anaesthesia had a more rapid onset of action, produced more effective sensory and motor blockade and had a shorter recovery period. Prilocaine appeared to be a safe local anaesthetic for use with either continuous spinal anaesthesia or continuous epidural anaesthesia.
PMID: 12553385, UI: 22440416
Eur J Anaesthesiol 2003 Jan;20(1):1-9
University of Manchester, Manchester, UK. brian.pollard@man.ac.uk
This study reports a review of all comparative published studies of adult day case anaesthesia in the English language up to December 2000. Ten databases were searched using appropriate keywords and data were extracted in a standardized fashion. One hundred-and-one published studies were examined. Recovery measurements were grouped as early, intermediate, late, psychomotor and adverse effects. With respect to induction of anaesthesia, propofol was superior to methohexital, etomidate and thiopental, but equal to sevoflurane and desflurane. Desflurane and sevoflurane were both superior to thiopental. There was no detectable difference between sevoflurane and isoflurane. With respect to the maintenance of anaesthesia, isoflurane and halothane were the worst. There were no significant differences between propofol, desflurane, sevoflurane and enflurane. Propofol is the induction agent of choice in day case patients. The use of a propofol infusion and avoidance of nitrous oxide may help to reduce postoperative nausea and vomiting.
PMID: 12553381, UI: 22440412
J Oral Maxillofac Surg 2003 Jan;61(1):61-4
Trauma Research Center Faculty, Baqiyatallah Medical Sciences University, Tehran, Iran. motamedical@mailcity.com
PURPOSE: This descriptive analytical study assesses the cause, type, incidence, demographic, and treatment data of maxillofacial fractures managed at our medical center during a 5-year period and compares them with the existing body of literature on the subject. PATIENTS AND METHODS: A 5-year retrospective clinical and epidemiologic study evaluated 237 patients treated for maxillofacial fractures from 1996 to 2001 at one medical center. There were 211 male patients (89%) and 26 (11%) female patients. The patients ranged in age from 3 to 73 years, with 59.0% (140 patients) in the 20- to 29-year age group. A number of parameters, including age, gender, cause of injury, site of injury, type of injury, treatment modalities, and complications, were evaluated. All maxillofacial injuries were assessed and treated by a single oral and maxillofacial surgeon. Other concomitant bodily injuries were treated by appropriate consultant specialists. RESULTS: There were 173 (72.9%) mandibular, 33 (13.9%) maxillary, 32 (13.5%) zygomatic, 57 (24.0%) zygomatico-orbital, 5 (2.1%) cranial, 5 (2.1%) nasal, and 4 (1.6%) frontal injuries. Car accidents caused 73 (30.8%), motorcycle accidents caused 55 (23.2%), altercations 23 (9.7%), sports 15 (6.3%), and warfare caused 23 (9.7%) of the maxillofacial injuries. Regarding distribution of mandibular fractures, 32% were seen in the condylar region, 29.3% in the symphyseal-parasymphyseal region, 20% in the angle region, 12.5% in the body, 3.1% in the ramus, 1.9% in the dentoalveolar, and 1.2% in the coronoid region. The distribution of maxillary fractures was Le Fort II in 18 (54.6%), Le Fort I in 8 (24.2%), Le Fort III in 4 (12.1%), and alveolar in 3 (9.1%). Of the 173 mandibular fractures, 56.9% were treated by closed reduction, 39.8% by open reduction, and 3.5% by observation only. Of 33 maxillary fractures, 54.6% were treated using closed reduction, 40.9% using open reduction, and 4.5% with observation only. Approximately 52.1% of the patients were treated under general anesthesia, and 47.9% were treated under local anesthesia and sedation. Postsurgical complications were recorded in 5% of patients. These complications included infection, asymmetry, and malocclusion. Overall mortality in this series was 0.84% (2 patients); mortality was caused by pulmonary infection. CONCLUSION: The findings of this study, compared with similar studies reported in the literature, support the view that the causes and incidence of maxillofacial injuries vary from 1 country to another. Copyright 2003 American Association of Oral and Maxillofacial Surgeons
PMID: 12524610, UI: 22412336