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[Death on the operating table. Anesthesiologic and medicolegal aspects]
[Article in German]
Dettmeyer R, Reber A.
Institut fur Rechtsmedizin, Bonn, Germany.
Since death on the operating table is a relatively rare incident, it raises a number of special medicolegal questions that are discussed in this article. One of the major concerns for medical personnel is being accused of malpractice during treatment, as it is an obvious presumption on the part of laymen that death was directly related to the medical treatment as compared with other in-hospital deaths. Questions such as who is responsible for issues of informed consent and liability are discussed. Other important aspects such as communication with the bereaved, transparent chronological documentation of the death circumstances, questions regarding certification of death, questions arising from autopsy done to determine the reason of death, questions about malpractice, legal requirements concerning confidential medical communication and information about what must be sent to the professional indemnity insurance company are elucidated. There is also some special information presented for cases that involve the deaths of Jehovah's Witnesses.
Publication Types:
PMID: 14714560 [PubMed - indexed for MEDLINE]
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[Liability of the anesthesiologist for medical records. Lead ruling by the Austrian High Court and comparison with the Austrian and German legal position]
[Article in German]
Lissel PM.
Kunz Schima Wallentin Rechtsanwalte KEG, Wien, Osterreich. Patrick.Lissel@ksw.at
PMID: 14691632 [PubMed - indexed for MEDLINE]
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[Melagatran and ximelagatran. Pharmacologic characteristics and anesthesiological aspects]
[Article in German]
Pindur G, Ziegeler S, Kleinschmidt S.
Abteilung fur Klinische Hamostaseologie und Transfusionsmedizin, Universitatskliniken des Saarlandes, Homburg/Saar.
Melagatran is a direct inhibitor of thrombin and-like its oral prodrug ximelagatran-a newly developed dipetide with high antithrombotic efficacy. They present a linear dose-response, a short plasma half-life and the therapeutic range may be advantageous compared with classic anticoagulants such as heparins or vitamin K antagonists. The results of clinical studies for prevention and treatment of thromboembolic complications are encouraging. The use of melagatran and ximelagatran will gain significance in the perioperative management, thus being of particular importance for anaesthesiology and critical care medicine in the near future.
Publication Types:
PMID: 14691631 [PubMed - indexed for MEDLINE]
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[Does chewing gum have consequences for anesthesia? A case report]
[Article in German]
Keppler V, Knuttgen D, Vorweg M, Doehn M.
Abteilung fur Anaesthesiologie, Krankenhaus Koln-Merheim, Kliniken der Stadt Koln. KepplerV@kliniken-koeln.de
Chewing gum is a common habit. Based on two cases of esophageal obstruction during induction of general anesthesia, the importance of chewing gum for anesthesiology is outlined. The dangers of chewing gum result from obstruction of the trachea and oesophagus but complications may also result from stimulated production of gastric juice with a risk of consecutive regurgitation and aspiration. In the case of an obstacle in the oesophagus when inserting a nasogastric tube, an obstruction by a mass of chewing gum should be considered. Although the literature provides differing statements concerning the volume and acidity of gastric juice after chewing gum, the use of chewing gum should be included in preanesthetic NPO rules.
Publication Types:
PMID: 14691628 [PubMed - indexed for MEDLINE]
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[The Narcotrend monitor. Development and interpretation algorithms]
[Article in German]
Schultz B, Kreuer S, Wilhelm W, Grouven U, Schultz A.
Klinikum Hannover Oststadt, Medizinische Hochschule Hannover. info@narcotrend.de
The Narcotrend performs an automatic interpretation of the electroencephalogram (EEG) during anaesthesia. The classification algorithms have been developed on the basis of visually classified EEG epochs. The classification scheme which was used for these visual assessments has its origin in sleep analysis and was adapted for the EEG during anaesthesia. From the awake state to very deep anaesthesia, 15 stages (A, B(0-2), C(0-2), D(0-2), E(0-2), F(0-1)) are distinguished. The transformation of these stages into a numerical scale from 100 to 0 is a further refinement for a differentiated presentation of EEG effects. For the automatic classification multivariate discriminant functions are used. Age-related changes of the EEG were incorporated. The device contains functions for the identification of artifacts. The EEG can be recorded from a frontal channel using standard ECG electrodes, other electrode positions and types can be chosen. The device has been clinically and scientifically validated.
Publication Types:
PMID: 14691627 [PubMed - indexed for MEDLINE]
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[Anesthetic regimen for HIV positive parturients undergoing elective cesarean section]
[Article in German]
Bremerich DH, Ahr A, Buchner S, Hingott H, Kaufmann M, Faul-Burbes C, Kessler P.
Klinik fur Anasthesiologie, Intensivmedizin und Schmerztherapie, Klinikum der Johann Wolfgang Goethe-Universitat Frankfurt, Frankfurt. Bremerich@em.uni-frankfurt.de
OBJECTIVE: Worldwide, 50 million people are infected with the human immunodeficiency virus (HIV), and 43% are women. Perinatal vertical transmission of HIV accounts for most new pediatric cases. Elective Cesarean delivery, combined antiretroviral therapy perioperatively and abandonment of breast-feeding postoperatively reduces vertical HIV transmission. However, the incidence of maternal and neonatal morbidity perioperatively is relatively unknown. The goal of the present study was to prospectively record perioperative maternal and neonatal complications in the largest HIV positive collective undergoing elective Cesarean section with spinal anesthesia published to date. METHODS: From 1999-2001, 54 HIV positive parturients were enrolled in this study. All parturients received IV zidovudine therapy (2 mg/kg body weight) perioperatively. Spinal anesthesia was performed using 60 mg of 4% hyperbaric mepivacaine plus 5 microg sufentanil intrathecally. Sensory, analgesic and motor block characteristics, the incidence of maternal hypotension, postoperative maternal complications as well as neonatal outcome were recorded. RESULTS: Short-term hypotension occurred in 65% of the parturients. Intraoperatively, one parturient died following amniotic fluid embolism. In 17% of the parturients, postoperative complications headed by wound healing impairment, bronchitis and pneumonia requiring prolonged antibiotic therapy were observed. To date, after a minimum observation period of 8 months, only one infant (1.8%) is HIV positive. CONCLUSION: Intrathecal mepivacaine combined with sufentanil in HIV positive parturients undergoing elective Cesarean section is an appropriate anesthetic option. Postoperative maternal morbidity was 17%. Neonatal outcome showed no evidence of neonatal depression.
Publication Types:
PMID: 14691624 [PubMed - indexed for MEDLINE]
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[Toxicology of local anesthetics. Clinical, therapeutic and pathological mechanisms]
[Article in German]
Zink W, Graf BM.
Klinik fur Anaesthesiologie, Universitatsklinikum Heidelberg. Wolfgang_Zink@med.uni-heidelberg.de
Regardless of their specific physico-chemical properties and chemical structures, all local anaesthetic agents block neuronal voltage-gated sodium channels, and thus suppress conduction in peripheral nerves. Since these ion channels ubiquitously appear in excitable membranes, systemic accumulation of local anaesthetic agents may affect the functional integrity of these structures. Clinically, local anaesthetic-induced systemic toxicity results in central nervous and cardiovascular malfunction. With regard to CNS toxicity, symptoms which are largely drug-independent appear in a characteristic biphasic sequence. Nevertheless, the plasma levels necessary to provoke these symptoms are to a large extent agent-specific. Initially, these toxic mechanisms are due to a selective blockade of cortical inhibitory neurons, which enables the formation of seizure potentials within subcortical structures. With high cerebral drug levels, however, excitatory neurons are also increasingly blocked, resulting in coma, apnoeic episodes and circulatory failure. Direct cardiac effects of local anaesthetics can be divided into (i) stereospecific inhibition of intracardial conduction and (ii) unspecific inhibition of myocardial energy supply and ion channels. The corresponding spectrum of symptoms is not uniform and may range from extreme bradycardia, (malignant) ventricular arrhythmia to refractory cardiac arrest. Local tissue toxicity has to be strictly delimited from systemic toxicity and allergies, respectively, which are mainly caused by aminoester agents. Local anaesthetics may cause neuronal and striated muscle injury at the site of injection. With regard to (central) neurotoxicity, "transient neurologic symptoms" and "cauda equina syndrome" have been increasingly recognised. However, the clinical relevance of local anaesthetic-induced myotoxicity is still controversly discussed. In order to avoid systemic accumulation of local anaesthetic agents, several safety procedures have to be considered during the application of these drugs. The treatment of systemic toxicity is strictly dependent on the expression of symptoms. However, hypoxia and acidotic episodes must be avoided and must be treated aggressively.
Publication Types:
PMID: 14691623 [PubMed - indexed for MEDLINE]
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[Haemodynamic effects following preoperative hypervolemic haemodilution with hypertonic hyperoncotic colloid solutions in coronary artery bypass graft surgery]
[Article in German]
Molter GP, Soltesz S, Larsen R, Baumann-Noss S, Biedler A, Silomon M.
Klinik fur Anaesthesie und operative Intensivmedizin, Klinikum Leverkusen gGmbH, Leverkusen. molter@klinikum-lev.de
OBJECTIVE: Using hyperoncotic colloids as volume replacement to provide haemodynamic stability appears to be a suitable approach to diminish fluid overload and subsequent interstitial edema during cardiac surgery. The aim of the present study was to investigate for the first time the haemodynamic effects following preoperative haemodilution with different hypertonic hyperoncotic colloid solutions in patients undergoing coronary artery bypass grafting. METHODS: A total of 43 patients with normal left ventricular ejection fraction, undergoing elective coronary artery bypass grafting received preoperatively after induction of anaesthesia according to randomisation the following solutions: 1: 750 ml/m(2) (body surface area) NaCl 0.9% ( n=10, control group, NACL), 2: 250 ml/m(2) 10% HES 200/0.5 plus 400 ml/m(2) NaCl 0.9% ( n=9, HES), 3: 250 ml/m(2) 10% dextran 40 plus 300 ml/m(2) NaCl 0.9% ( n=8, DEX), 4: 150 ml/m(2) hypertonic NaCl (7.2%) 10% HES 200/0.5 (n=8, HYPER-HES), 5: 150 ml/m(2) hypertonic NaCl (7.2%) 10% dextran 60 ( n=8, HYPER-DEX). Haemodynamic measurements were performed immediately before and 15 min after haemodilution and up to 60 min after termination of extracorporeal circulation in 10 min intervals. Fluid balances were calculated separately, during the time period of surgery, postoperatively up to 24 h after termination of surgery, and during the course of extracorporeal circulation. RESULTS: After haemodilution with colloid solutions, a marked increase was observed in all patients and with HYPER-HES and HYPER-DEX a statistically significant increase in cardiac index (CI: +38%, +54%), stroke volume index (SVI: +42%, +40%), and oxygen availability (DO2: +34%; +41%), respectively, was observed during the pre-bypass period. At the same time right and left ventricular filling pressures increased slightly in all patients but these changes did not differ among the treatment groups. Heart rate and mean arterial pressure remained almost unchanged in all groups. The amount of crystalloid solutions required by the patients during surgery was markedly decreased with HES and DEX and significantly decreased with HYPER-HES and HYPER-DEX (1,013+/-341 ml/m(2), 1,096+/-234 ml/m(2)) compared to the control group NACL (1629+/-426 ml/m(2)). Serum sodium concentrations increased with HYPER-HES and HYPER-DEX to maximal values of 150+/-3 mmol/l and 149+/-4 mmol/l, respectively (baseline 141+/-3 mmol/l, 141+/-1 mmol/l) CONCLUSIONS: Compared to isotonic saline solution, preoperative volume replacement with hyperoncotic colloids improves haemodynamic conditions during the pre-bypass period in patients with normal left ventricular function undergoing coronary artery bypass grafting. Additionally intraoperative crystalloid solution requirements are reduced. The volume saving effects are increased with administration of hyperoncotic colloids in a preparation with hypertonic saline solution, whereas the choice of the colloid, either hydroxyethyl starch or dextran seems to be of minor importance.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 14618246 [PubMed - indexed for MEDLINE]
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Strap him down or knock him out: Is conscious sedation with restraint an alternative to general anaesthesia?
Kupietzky A.
1Clinical Instructor, Department of Pediatric Dentistry, Hebrew University-Hadassah School of Dental Medicine, Jerusalem, Israel.
When confronting a defiant or pre-co-operative young patient with extensive dental decay the dentist must decide between treatment under conscious sedation with passive restraint or general anaesthesia. Although some practitioners prefer to attempt and exhaust sedative techniques in most cases and use general anaesthesia as a last resort, many others do not mandate that alternate approaches first be attempted before treating under general anaesthesia and routinely recommend it as their first choice. What are the considerations involved in this decision-making process? Should the use of conscious sedation with restraint be revisited and perhaps even be considered the preferred method? What is the role of the dentist in the decision-making process? The purpose of this opinion-based paper is to present to the UK dentist a dilemma that paediatric dentists face in the US and in other countries as well and allow the reader to establish an opinion.
PMID: 14963430 [PubMed - in process]
Sore throat and hoarseness after total intravenous anaesthesia.
Maruyama K, Sakai H, Miyazawa H, Toda N, Iinuma Y, Mochizuki N, Hara K, Otagiri T.
Department of Anesthesiology, Iida Municipal Hospital, 438 Yawata, Iida City, Nagano 395-8502, Japan.
BACKGROUND: Sore throat and hoarseness are common complications, but these have not been studied after total i.v. anaesthesia. METHODS: We prospectively studied 418 surgical patients, aged 15-92 yr, after total i.v. anaesthesia with propofol, fentanyl and ketamine to assess possible factors associated with sore throat and hoarseness.Result. We found sore throat in 50% and hoarseness in 55% of patients immediately after surgery. This decreased to 25% for sore throat and 24% for hoarseness on the day after surgery. Both sore throat and hoarseness were more common in females and when lidocaine spray had been used. Cricoid pressure during laryngoscopy was inversely associated with the risk of sore throat. CONCLUSION: Knowledge of these factors may reduce postoperative throat complications, and improve patient satisfaction.
PMID: 14766717 [PubMed - as supplied by publisher]
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Density of spinal anaesthetic solutions of bupivacaine, levobupivacaine, and ropivacaine with and without dextrose.
McLeod GA.
Ninewells Hospital and Medical School, Dundee, Scotland DD1 9SY, UK.
BACKGROUND: Spread of intrathecal local anaesthetics is determined principally by baricity and position of the patient. Hypobaric solutions of bupivacaine are characterized by an unpredictable spread of sensory block whereas addition of dextrose 80 mg ml(-1) provides a predictable spread but to high thoracic levels. In contrast, dextrose concentrations between 8 and 30 mg ml(-1) have shown reliable and consistent spread for surgery. Hence, the aim of this study was to determine the density of bupivacaine, levobupivacaine, and ropivacaine with and without dextrose at both 23 and 37 degrees C before embarking on clinical studies. METHODS: Density (mg ml(-1)) was measured using the method of mechanical oscillation resonance, accurate to five decimal places on 1250 samples. 500 density measurements were performed in a randomized, blind fashion at 23 and 37 degrees C on 10 plain solutions of bupivacaine (2.5, 5, and 7.5 mg ml(-1)) levobupivacaine (2.5, 5, and 7.5 mg ml(-1)) and ropivacaine (2, 5, 7.5, and 10 mg ml(-1)). Following this, 750 density measurements were taken at 23 and 37 degrees C on the 5 mg ml(-1) solutions of bupivacaine, levobupivacaine, and ropivacaine with added dextrose (10, 20, 30, 50, and 80 mg ml(-1)). RESULTS: There was a linear relationship between density and dextrose concentration for all three local anaesthetics (R(2)=0.99) at 23 and 37 degrees C. The mean density of levobupivacaine 5 mg ml(-1) was significantly greater than the densities of bupivacaine 5 mg ml(-1) and ropivacaine 5 mg ml(-1) after adjusting for dextrose concentration using analysis of covariance. This difference existed both at 23 and 37 degrees C. The mean (SD) density of levobupivacaine 7.5 mg ml(-1) was 1.00056 (0.00003) mg ml(-1), the lower 0.5% percentile (1.00047 mg ml(-1)) lying above the upper limit of hypobaricity for all patient groups. CONCLUSIONS: The density of local anaesthetics decreases with increasing temperature and increases in a linear fashion with the addition of dextrose. Levobupivacaine 5 mg ml(-1) has a significantly higher density compared with bupivacaine 5 mg ml(-1) and ropivacaine 5 mg ml(-1) at 23 and 37 degrees C both with and without dextrose. Levobupivacaine 7.5 mg ml(-1) is an isobaric solution within all patient groups at 37 degrees C.
PMID: 14766715 [PubMed - as supplied by publisher]
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Randomized, controlled trial of the double setup tracheal tube during fibreoptic orotracheal intubation under general anaesthesia.
Jackson AH, Wong P, Orr B.
Department of Anaesthetics, Royal Prince Alfred Hospital, Missenden Road, Camperdown 2050, New South Wales, Australia.
BACKGROUND: Impingement of the tracheal tube (ETT) on upper airway structures during railroading over the fibreoptic bronchoscope (FOB) occurs commonly. Potential complications of impingement include prolonged intubation time, leading to arterial desaturation, failed intubation and laryngeal trauma. The objective of this randomized, controlled trial was to assess the effect of the double setup ETT (a paediatric ETT is placed inside an adult ETT) on the incidence of impingement during orotracheal fibreoptic intubation.Method. Two hundred patients were randomized to have a single ETT or double setup ETT. After induction of anaesthesia, fibreoptic orotracheal intubation was performed. The degree of impingement of the ETT during advancement over the FOB was assessed using a standardized scoring system based on the manoeuvres required to overcome the impingement. RESULTS: The incidence of impingement was lower using the double setup ETT compared with the single ETT (18 vs 93%, P<0.001). The double setup ETT also reduced the incidence of impingement requiring more than a simple 90 degrees counterclockwise rotation to achieve intubation (3 vs 14%, P=0.01) and reduced the median intubation time (31 vs 35 s, P=0.046). CONCLUSIONS: The double setup ETT is effective in reducing ETT impingement and in reducing intubation time. We did not find an association between ETT impingement and arterial desaturation.
PMID: 14766713 [PubMed - as supplied by publisher]
Clonidine attenuates the hemodynamic responses to hypercapnia during propofol anesthesia.
Uchida M, Iida H, Osawa Y, Tanahashi S, Kumazawa M, Sumi K, Dohi S.
Gifu, Japan.
PMID: 14766702 [PubMed - in process]
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Acute airway management in the emergency department by non-anesthesiologists: [L'assistance respiratoire immediate realisee a l'urgence par des non-anesthesiologistes].
Kovacs G, Law JA, Ross J, Tallon J, MacQuarrie K, Petrie D, Campbell S, Soder C.
Departments of Emergency Medicine and Anesthesia, Dalhousie University, Halifax, Nova Scotia, Canada.
PURPOSE: The responsibility of acute airway management often falls into the hands of non-anesthesiologists. Emergency physicians now routinely use neuromuscular blockade to facilitate intubation. The literature in support of this practice has almost exclusively been published in emergency medicine (EM) journals. This body of literature is presented and issues of educational support are discussed. SOURCE: A narrative review of the literature on the practice of airway management by non-anesthesiologists. Principal findings: A significant proportion of acute airway management occurring outside the operating room is being performed by non-anesthesiologists. Rapid sequence intubation (RSI) is recognized as a core procedure within the domain of EM. RSI is being performed routinely by emergency physicians practicing in larger centres. Anesthesiologist support for the practice of RSI by non-anesthesiologists has been weak. Formal educational support outside of postgraduate training in the form of dedicated programs for advanced airway management are now being offered. The majority of the literature on the use of RSI by non-anesthesiologists represents retrospective case series, observational studies and registry data published in EM journals. The reported success rates for RSI performed by non-anesthesiologists is high. Complication rates are significant, however reporting consistency has been poor. CONCLUSIONS: The role of non-anesthesiologists in acute airway management is significant. Despite shortcomings in methodology, current evidence and practice supports the use of RSI by trained emergency physicians. Constructive collaborative efforts between anesthesiology and EM need to occur to ensure that educational needs are met and that competent airway management is provided.
PMID: 14766697 [PubMed - in process]
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Images in Anesthesia: A right atrial foreign body.
Yao L, Veytsman AM, Dhamee MS.
Milwaukee, Wisconsin.
PMID: 14766696 [PubMed - in process]
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Ultra-fast-track anesthesia in off-pump coronary artery bypass grafting: a prospective audit comparing opioid-based anesthesia vs thoracic epidural-based anesthesia: [Un mode anesthesique ultrarapide pendant le pontage aortocoronarien a coeur battant : un audit prospectif comparant l'anesthesie avec opioides et l'anesthesie peridurale thoracique].
Hemmerling TM, Prieto I, Choiniere JL, Basile F, Fortier JD.
Departments of Anesthesiology and Surgery, Centre hospitalier de l'universite de Montreal (CHUM), Hotel-Dieu, Universite de Montreal, Montreal, Quebec, Canada.
PURPOSE: To examine the feasibility of immediate extubation after off-pump coronary artery bypass grafting (OPCAB) using opioid based analgesia or high thoracic epidural analgesia (TEA) and compare postoperative analgesia with continuous TEA vs patient-controlled analgesia (PCA). METHODS: One hundred consecutive patients undergoing OPCAB were included in this prospective audit. After induction of anesthesia using fentanyl 2 to 5 micro g*kg(-1), propofol 1 to 2 mg*kg(-1) and endotracheal intubation facilitated by rocuronium, anesthesia was maintained using sevoflurane titrated according to bispectral index monitoring. Perioperative analgesia was provided by TEA (n = 63) at the T3/T4 interspace or T4/T5 interspace using bupivacaine 0.125% 8 to 14 mL*hr(-1) and repetitive boluses of bupivacaine 0.25% during surgery. In patients who were fully anticoagulated or refused TEA, perioperative analgesia was achieved by iv fentanyl boluses (up to 15 micro g*kg(-1)) and remifentanil 0.1 to 0.2 micro g*kg(-1)*min(-1), followed by morphine PCA after surgery (n = 37). Maintenance of body temperature was achieved by a heated operating room and forced-air warming blankets. RESULTS: Ninety-five patients were extubated within 25 min after surgery (PCA, n = 33; TEA, n = 62). Five patients were not extubated immediately because their core temperature was lower than 35 degrees C. One patient was re-intubated because of agitation (TEA group); one was re-intubated because of severe pain and morphine-induced respiratory depression (PCA group). Pain scores were low after surgery, with pain scores in the TEA group being significantly lower immediately, at six hours, 24 hr and 48 hr after surgery (P < 0.05). CONCLUSION: Immediate extubation is possible after OPCAB using either opioid-based analgesia or TEA. TEA provides significantly lower pain scores after surgery in comparison to morphine PCA.
PMID: 14766694 [PubMed - in process]
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The cocaine abusing parturient: a review of anesthetic considerations: [L'abus de cocaine chez les parturientes : une revue des aspects anesthesiques].
Kuczkowski KM.
Departments of Anesthesiology and Reproductive Medicine, University of California San Diego, San Diego, California, USA.
PURPOSE: The prevalence of recreational drug abuse among young women, including in pregnancy, has increased markedly over the past two decades. Cocaine remains the drug commonly used for recreational purposes in pregnancy. However, there appears to be an absence of uniform guidelines for obstetric and anesthetic management of pregnant patients with a history of cocaine abuse. SOURCE: A Medline search for articles highlighting drug abuse in pregnancy, with particular emphasis on cocaine abuse in pregnancy, the drug's impact on the fetus and implications for administration of obstetrical anesthesia was performed. Main findings: Because the pharmacological actions of cocaine are complex, the clinical picture can be very unpredictable, the diagnosis often difficult, and management at times controversial. The diverse clinical symptomatology of cocaine intake combined with physiologic changes of pregnancy, and pathophysiology of co-existing pregnancy specific disease may lead to life-threatening complications and significantly impact the management of obstetrical anesthesia. CONCLUSIONS: In the absence of uniform anesthetic guidelines for pregnant patients with a history of cocaine abuse the decision regarding the administration of peripartum analgesia or anesthesia should be individualized and conducted on a case-by-case basis. This article will attempt to heighten the awareness of cocaine use and abuse in pregnancy and review the perioperative anesthetic management of these high-risk parturients.
PMID: 14766691 [PubMed - in process]
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Pheochromocytoma and pregnancy: a case report and review of anesthetic management: [Pheochromocytome et grossesse. Expose d'un cas et revue de la demarche anesthesique].
Dugas G, Fuller J, Singh S, Watson J.
Department of Anesthesia and Perioperative Medicine, St. Joseph's Health Care, University of Western Ontario, London, Ontario, Canada.
PURPOSE: To describe a patient diagnosed with pheochromocytoma in the third trimester of pregnancy and discuss the perioperative and anesthetic management. Clinical features: A 32-yr-old previously healthy woman (gravida 4, para 2) presented to our tertiary care obstetrical hospital at 34 weeks five days gestation with a history of labile blood pressure and severe hypertension. A week prior to admission she began having episodes of severe headache, dizziness, sweating and nausea. On a routine obstetric visit she was noted to be severely hypertensive with a blood pressure of 200/120 mmHg. Biochemical investigations confirmed the diagnosis of pheochromocytoma and magnetic resonance imaging demonstrated a 3 cm x 3 cm right adrenal mass. The patient was invasively monitored in the intensive care unit and treated with alpha- followed by beta-blockade with phenoxybenzamine and metoprolol. A multidisciplinary conference was organized involving endocrinology, anesthesiology, general surgery and obstetrics to determine the most appropriate management of the patient. An uncomplicated laparoscopic adrenalectomy was performed following a period of recovery after an uneventful elective Cesarean delivery. CONCLUSIONS: The primary goals in the management of pheochromocytoma in pregnancy are early diagnosis, avoidance of a hypertensive crisis during delivery and definitive surgical treatment. Timing of surgical resection will depend on the gestational age at which diagnosis is made. Cesarean section is the preferred mode of delivery when the tumour is still present. This case illustrates that with antenatal diagnosis, advanced methods of tumour localization, adequate preoperative adrenergic blockade and team planning, pheochromocytoma in pregnancy can be treated successfully.
PMID: 14766689 [PubMed - in process]
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Anaesthesia for a life-limited child with adrenoleucodystrophy.
Dobson G, Lyons J.
Publication Types:
PMID: 14768930 [PubMed - in process]
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Laparoscopic live donor nephrectomy: the anaesthesiologist's perspective.
Biancofiore G, Amorese G, Lugli D, Bindi L, Fossati N, Boggi U, Pietrabissa A, Mosca F.
Publication Types:
PMID: 14768928 [PubMed - in process]
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A multicentre trial comparing different concentrations of ropivacaine plus sufentanil with bupivacaine plus sufentanil for patient-controlled epidural analgesia in labour.
Gogarten W, Van de Velde M, Soetens E, Van Aken H, Brodner G, Gramke HF, Soetenst M, Marcus MA.
Universitatsklinikum Munster, Department of Anaesthesiology and Intensive Care, Germany.
BACKGROUND AND OBJECTIVE: To determine the optimal concentration of ropivacaine for bolus-only patient-controlled epidural labour analgesia, three different doses of ropivacaine were evaluated in comparison with bupivacaine in a double-blinded multicentre study. METHODS: Four hundred-and-fifty labouring parturients at term in three different academic institutions were randomized to four groups receiving bupivacaine 0.125% with sufentanil 0.75 microg mL(-1), ropivacaine 0.125% or 0.175% with sufentanil 0.75 microg mL(-1), or ropivacaine 0.2%. After an initial bolus of 10 mL of the study solution, and once visual analogue scores (VAS) were below 30 mm, patient-controlled epidural analgesia was initiated with a bolus of 4 mL, a lockout interval of 15 min and without a background infusion. Variables studied were the quality of analgesia, incidence of side-effects, the degree of motor blockade, and the mode of delivery. RESULTS: Bupivacaine 0.125% and ropivacaine 0.125% with sufentanil proved equally effective in providing labour analgesia without a difference in local anaesthetic consumption (48.6 +/- 23 mg bupivacaine vs. 52.1 +/- 38 mg ropivacaine), motor blockade or mode of delivery. Ropivacaine 0.175% plus sufentanil enhanced the quality of analgesia of the initial loading dose, whereas ropivacaine 0.2% without sufentanil increased the consumption of local anaesthetics (80.2 +/- 34 mg; P < 0.05) and the degree of motor blockade. CONCLUSION: Despite recent studies indicating that bupivacaine and ropivacaine may not be equipotent, both local anaesthetics provided equi-effective analgesia at equal doses without a difference in side-effects.
PMID: 14768922 [PubMed - in process]
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Real-time ultrasonic observation of combined spinal-epidural anaesthesia.
Grau T, Leipold RW, Fatehi S, Martin E, Motsch J.
University of Heidelberg, Department of Anaesthesiology, Heidelberg, Germany. thomas_grau@med.uni-heidelberg.de
BACKGROUND AND OBJECTIVE: The quality of combined spinal-epidural anaesthesia mainly depends on accurate identification of the epidural space. The real-time ultrasound control of the procedure for puncture was therefore evaluated. METHODS: Thirty parturients scheduled for Caesarean section were randomized to three equal groups. Ten control patients received conventional combined spinal-epidural anaesthesia. Ten of the remaining patients received ultrasonic scans by an offline scan technique, and 10 received online imaging of the lumbar region during epidural puncture. The epidural space was identified and needle advancement was surveyed through the interspinal and flaval ligaments. The number of attempts to advance the needle to achieve a successful puncture was measured and compared, as well as the number of vertebral interspaces punctured before successful entry into the epidural space. RESULTS: There was no difference between patient characteristics in the three groups. The visualization of the epidural structures and of the needle manipulations was very effective. In the ultrasound group, the reduction in the number of attempts at puncture was significant (P < 0.036). The number of interspaces necessary for puncture was reduced (P < 0.036) in the ultrasound online group compared with controls. The number of spinal needle manipulations was significantly reduced (P < 0.036). CONCLUSIONS: Real-time ultrasonic scanning of the lumbar spine is an easy procedure. It provides an accurate reading of the location of the needle tip and facilitates the performance of combined spinal-epidural anaesthesia.
PMID: 14768920 [PubMed - in process]
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Mood change after anaesthesia with remifentanil or alfentanil.
Crozier TA, Kietzmann D, Dobereiner B.
University of Gottingen, Department of Anaesthesiology, Gottingen, Germany. tcrozie@gwdg.de
BACKGROUND AND OBJECTIVE: There are anecdotal reports of dysphoria occurring in patients on the first day after anaesthesia with remifentanil. This study was performed to investigate this allegation and to find a possible relationship to postoperative shivering or to nausea and vomiting. METHODS: Patients undergoing otorhinolaryngeal surgery took part in a prospective, randomized, double-blind study comparing total intravenous anaesthesia with propofol (2 mg kg(-1) bolus injection then 100 microg kg(-1) min(-1)) and remifentanil (1 microg kg(-1) bolus then 0.1-0.5 microg kg(-1) min-1) or alfentanil (30 microg kg(-1) bolus then 0.16-0.83 microg kg((-1) min(-1)). The patients were carefully insulated and actively warmed by convective heating and rectal temperature was monitored continuously. Postoperative shivering was graded on a three-point scale, and the cumulative incidence of nausea and vomiting were registered at 24 h after surgery. Pre- and postoperative mood was measured with the von Zerssen mood scale (Befindlichkeits-Skala) and changes tested for significance. High scores reflect discontent and dysphoria. RESULTS: The data of 98 patients (49 in each group, ASA I-II, age 42 +/- 13 yr, anaesthesia time 141 +/- 60 min; mean +/- SD; intergroup P values > 0.1) were evaluated. Core temperature did not change perioperatively (before 36.6 +/- 0.2 degrees C; after 36.8 +/- 0.3 degrees C, inter- and intragroup P > 0.1). The incidence of nausea was the same in each group; vomiting occurred with equal frequency (6/49 vs. 7/49). Shivering was significantly more frequent after remifentanil (41% vs. 10%, P < 0.001). The patients' mood remained stable after remifentanil but worsened after alfentanil (von Zerssen score from 9.3 +/- 2.5 to 13.9 +/- 3.6; mean +/- 95% confidence intervals; P < 0.01). DISCUSSION: Postoperative shivering was more frequent after remifentanil but was unrelated to intraoperative heat loss. Contrary to preliminary informal observations, there was no evidence that remifentanil caused postanaesthetic dysphoria on the day one after surgery.
PMID: 14768919 [PubMed - in process]
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EEG-based indices of anaesthesia: correlation between bispectral index and patient state index?
Schneider G, Mappes A, Neissendorfer T, Schabacker M, Kuppe H, Kochs E.
Department of Anaesthesiology, Klinikum rechts der Isar, Technische Universitat Munchen, Germany. Gerhard.Schneider@LRZ.tum.de
BACKGROUND AND OBJECTIVE: Both the bispectral and the patient state indices are derived from the electroencephalogram and have been proposed as a measure of the same clinical target, the hypnotic component of anaesthesia. The present study evaluated whether there is concordance between the bispectral and the patient state indices with regard to end-points measured simultaneously in patients undergoing surgery under general anaesthesia. METHODS: Fifty-seven patients scheduled for elective abdominal, orthopaedic (Groups 1 and 2) or cardiac surgery (Group 3) under general anaesthesia were enrolled in the study. Anaesthesia was performed using remifentanil/ sevoflurane (Group 1, 19 patients), remifentanil/propofol (Group 2, 19 patients) or sufentanil/propofol/isoflurane (Group 3, 19 patients). The bispectral and the patient state indices were simultaneously recorded. Pearson's correlation between these two indices was calculated for the complete data and each group. The percentage of bispectral index values in the recommended range for general anaesthesia (45-60) that were confirmed by levels of patient state index (25-50) was calculated and vice versa. RESULTS: Overall correlation between the bispectral and the patient state indices was 0.667, 0.671 in Group 1, 0.650 in Group 2 and 0.675 in Group 3 (P < 0.01). For values of the bispectral index between 45 and 60, only 40% of corresponding patient state index values were between 25 and 50. For patient state index values of 25-50, only 50% of the corresponding bispectral index values were in the range of 45-60. CONCLUSIONS: Concordance between the bispectral and patient state indices is relatively weak, whereas both are thought to reflect the same clinical target, the hypnotic component of anaesthesia. As a consequence, further studies are required to compare reliability of both indices as indicators of different levels of hypnosis.
PMID: 14768917 [PubMed - in process]
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Retropharyngeal or cervicomediastinal haematomas following stellate ganglion block.
Okuda Y, Urabe K, Kitajima T.
Publication Types:
PMID: 12974602 [PubMed - indexed for MEDLINE]
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Prospective, randomized, controlled evaluation of the preventive effects of positive end-expiratory pressure on patient oxygenation during one-lung ventilation.
Mascotto G, Bizzarri M, Messina M, Cerchierini E, Torri G, Carozzo A, Casati A.
Vita-Salute University of Milan, IRCCS H. San Raffaele, Department of Anaesthesiology, Milan, Italy.
BACKGROUND AND OBJECTIVE: This prospective, randomized, controlled study evaluated the effects on oxygenation by applying a selective and patient-specific value of positive end-expiratory pressure (PEEP) to the dependent lung during one-lung ventilation. METHODS: Fifty patients undergoing thoracic surgery under combined epidural/general anaesthesia were randomly allocated to receive zero PEEP (Group ZEEP, n = 22), or the preventive application of PEEP, optimized on the best thoracopulmonary compliance (Group PEEP, n = 28). Patients' lungs were mechanically ventilated with the same setting during two- and one-lung ventilation (FiO2 = 0.5; VT = 9mL kg(-1), inspiratory :expiratory time = 1 : 1, inspiratory pause = 10%). RESULTS: Lung-chest wall compliance decreased in both groups during one-lung ventilation, but patients of Group PEEP had 10% higher values than patients with no end-expiratory pressure (ZEEP) applied--Group ZEEP (P < 0.05). During closed chest one-lung ventilation, the PaO2 : FiO2 ratio was lower in Group PEEP (232 +/- 88) than in Group ZEEP (339 +/- 97) (P < 0.05); but no further differences were reported throughout the study. No differences were reported between the two groups in the need for 100% oxygen ventilation (10 patients of Group ZEEP (45%) and 14 patients of Group PEEP (50%) (P = 0.78)) or re-inflation of the operated lung during surgery (two patients of Group ZEEP (9%) and three patients of Group PEEP (10%) (P = 0.78)). Postanaesthesia care unit discharge required 48 min (25th-75th percentiles: 32-58 min) in Group PEEP and 45 min (30-57 min) in Group ZEEP (P = 0.60). CONCLUSIONS: The selective application of PEEP to the dependent, non-operated lung increases the lung-chest wall compliance during one-lung ventilation, but does not improve patient oxygenation.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 12974591 [PubMed - indexed for MEDLINE]
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A history of neuraxial administration of local analgesics and opioids.
Brill S, Gurman GM, Fisher A.
Soroka University Medical Center, Faculty of Health Sciences, Division of Anesthesiology, Ben Gurion University of the Negev, Beer Sheva, Israel. s_bril@yahoo.com
The history of intrathecal and epidural anaesthesia is in parallel with the development of general anaesthesia. As ether anaesthesia (1846) is considered the first modern anaesthetic since its use by Morton 157 yr ago, so Bier made history by using cocaine for intrathecal anaesthesia in 1898. The first published report on opioids for intrathecal anaesthesia belongs to a Romanian surgeon, Racoviceanu-Pitesti, who presented his experience at Paris in 1901. It was almost a century before the opioids were used for epidural analgesia. Behar and his colleagues published the first report on the epidural use of morphine for the treatment of pain in The Lancet in 1979. Epidural and intrathecal opioids are today part of a routine regimen for intra- and postoperative analgesia. Over the last 30 yr, the use of epidural opioids has became a standard for analgesia in labour and delivery, and for the management of chronic pain. Finally, epidural opioids have been shown to have a pre-emptive effect, when used before major surgery. We present the evolution of neuraxial anaesthesia and the history of intrathecal and epidural administration of opioids.
Publication Types:
- Historical Article
- Review
- Review, Tutorial
PMID: 12974588 [PubMed - indexed for MEDLINE]
Acute limb ischemia does not facilitate but inhibits norepinephrine release from muscle sympathetic nerve endings in anesthetized rabbit.
Tokunaga N, Yamazaki T, Akiyama T, Sano S, Mori H.
Department of Cardiac Physiology, National Cardiovascular Center Research Institute, Osaka, Japan.
Although myocardial ischemia is associated with regional cardiac sympathetic nerve deterioration, it remains unknown whether acute hindlimb ischemia impairs muscle sympathetic nerve function. In the study presented here we implanted dialysis probes in the adductor muscle of anesthetized rabbits and measured dialysate norepinephrine levels as an index of muscle sympathetic nerve activity. Acute hindlimb ischemia was induced by injection of microspheres and occlusion of the common iliac artery. Dialysate norepinephrine levels decreased from 19.3 +/- 3.5 pg/ml at control to 9.4 +/- 3.7 pg/ml at 30 min of ischemia and further to 1.7 +/- 0.2 pg/ml at 75 min of ischemia. During acute hindlimb ischemia, baroreflex (bilateral carotid occlusion) and high potassium level-induced norepinephrine response was inhibited, but tyramine-induced norepinephrine response was preserved. In conclusion, acute hindlimb ischemia caused decreases in dialysate norepinephrine levels. This reduction may be mediated by an impairment of axonal conduction and/or of norepinephrine releasing function at skeletal muscle sympathetic nerve endings.
PMID: 14871020 [PubMed - in process]
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