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Anaesthetic management of Osler-Weber-Rendu syndrome with coexisting congenital methaemoglobinaemia.
Sharma D, Pandia MP, Bithal PK.
Department of Neuroanaesthesiology, Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, India.
A 9-year-old cyanosed child suffering from Osler-Weber-Rendu syndrome with bilateral pulmonary arteriovenous malformations (PAVMs) was posted for cerebral angiography under general anaesthesia. Careful preanaesthetic evaluation led to the diagnosis of coexisting congenital methaemoglobinaemia. There is no previous report of Osler-Weber-Rendu syndrome coexisting with congenital methaemoglobinaemia. This report emphasizes that a second contributory cause of cyanosis must be suspected and meticulously looked for if the symptomatology in a patient cannot be explained by a single established diagnosis. Positive-pressure ventilation was associated with reduction in arterial oxygenation despite an increasing inspired oxygen concentration, which returned to preanaesthetic levels only after extubation and resumption of spontaneous respiration.
PMID: 16146483 [PubMed - in process]
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N2O-free low-flow anesthesia technique for children.
Bozkurt P, Saygi Emir N, Tomatir E, Yeker Y.
Department of Anesthesiology and Reanimation, Istanbul University Cerrahpasa Medical Faculty, Istanbul, Turkey. apbs@istanbul.edu.tr
BACKGROUND: The use of N2O during low-flow anesthesia (LFA) causes difficulty in predicting inspired gas mixtures and oxygen concentration due to accumulation. An alternative technique, which uses a mixture of oxygen and air and a morphine infusion to replace N2O, has been evaluated in children during LFA, and the clinical effects and composition of gases in the system are presented here. METHODS: Thirty-five children aged 2-13 years undergoing major urogenital surgery were recruited into the study. Following a standardized induction, anesthesia was maintained with 2% sevoflurane in combination with a morphine infusion. After induction with 4 l min(-1), flow rates were reduced to 2 l min(-1) and finally to 1 l min(-1) at 10 min (0.5 l oxygen + 0.5 l air). The delivered oxygen concentration, oxygen saturation and the inspired and expired O2 sevoflurane and CO2 concentrations were recorded from the start of induction to the end of anesthesia. RESULTS: The duration of LFA was 132+/-89 min. The concentration of oxygen delivered by the flow meters during this period was 55-60%. Although the changes in inspired and expired oxygen and sevoflurane and inspired CO2 related to the duration of LFA were statistically significant (P < 0.0001), they were not clinically relevant. All vital parameters were stable. Four patients required supplemental morphine and nine presented emergence agitation. CONCLUSION: We concluded that an N2O-free LFA technique with 0.5 l min(-1) of air and 0.5 l min(-1) of O2 supplemented by sevoflurane and a morphine infusion is safe and effective in children. The resulting high-inspired oxygen concentration prevents occurrence of hypoxic gas mixtures, and the use of supplemental morphine compensates for the absence of N2O and overcomes the possibility of light anesthesia arising from a decrease in the inspired sevoflurane concentration.
PMID: 16146471 [PubMed - in process]
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Changes in the auditory evoked potentials index by induction doses of four different intravenous anesthetics.
Nishiyama T.
Department of Anesthesiology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan. nishit-tky@umin.ac.jp
BACKGROUND: Many studies have investigated the electroencephalographic changes during the induction and maintenance of anesthesia. However, no comparative studies have been performed on the effects of intravenous anesthetics on the auditory evoked potentials index (AAI). The present study was performed to compare the changes in AAI caused by induction doses of thiopental, propofol, midazolam and ketamine. METHODS: Eighty females, aged 30-70 years, referred for mastectomy, had anesthesia induced with thiopental 4 mg/kg, propofol 2 mg/kg, midazolam 0.1 mg/kg or ketamine 1 mg/kg (each 20 patients). The response to verbal command and the AAI were measured every minute for 5 min. RESULTS: The AAI decreased to less than 40 within 1 min with thiopental and propofol. The AAI increased after 3 min with thiopental, but remained low with propofol. The AAI gradually decreased to less than 40 within 4 min with midazolam, but was higher than the AAI with propofol or thiopental. The AAI increased significantly with ketamine. The AAIs at the loss of verbal command were 19 +/- 7 with thiopental, 21 +/- 8 with propofol, 31 +/- 10 with midazolam and 92 +/- 2 with ketamine. CONCLUSION: The AAI correlated with changes in hypnotic level, as measured by the response to verbal command, with induction doses of thiopental, propofol and midazolam, but not with ketamine. The AAI decreased to lower levels with propofol and thiopental than with midazolam at the induction of anesthesia.
PMID: 16146470 [PubMed - in process]
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Effects of anaesthesia using endotracheal intubation or the laryngeal mask airway, or spinal anaesthesia, on oral mucosal host defences during minor surgery.
Lahteenmaki M, Salo M, Tenovuo J, Vahlberg T.
Department of Anaesthesia, Satakunta Central Hospital, Pori, Finland. Merja.Lahteenmaki@satshp.fi
BACKGROUND: Oral mucosal host defences are altered after anaesthesia and surgery. The effects of endotracheal intubation (ET) and the use of the laryngeal mask airway (LMA) on oral mucosal host defences after minor surgery were compared. METHODS: Immunological (immunoglobulin A (IgA), IgG and IgM) and non-immunological (myeloperoxidase, total peroxidase, thiocyanate) oral host defence factors, and amylase and protein concentrations, were measured from saliva pre-operatively and on the first post-operative day in 60 ASA I-II patients undergoing minor surgery. The patients underwent general anaesthesia using oral ET or LMA. Spinal anaesthesia (S) was used as control. Serum IgG, IgM and IgA concentrations were determined. RESULTS: Protein-related salivary secretion of amylase and salivary concentration of IgM showed the only statistically significant overall differences between the groups. By contrast, changes were observed within the ET group in the salivary flow rate, protein concentration, amylase activity and immunological host defence factors. Some changes were also observed in the LMA group, but none in the S group. Most non-immunological test values did not change within any of the groups. CONCLUSIONS: ET and LMA induced similar oral mucosal host defence responses. There were, however, observations in this study that indicated a stronger response during ET than when LMA was used.
PMID: 16146469 [PubMed - in process]
Comment on:
Comparison of disposable and reusable laryngeal mask airways in spontaneously ventilating adult patients.
Al-Shaikh B, Mathew G, Van Zundert AA.
Publication Types:
PMID: 15973929 [PubMed - indexed for MEDLINE]
Neurosurgery in the sitting position: a case series.
Domaingue CM.
Department of Anaesthesia, St Vincent's Hospital, Melbourne, Victoria.
Prospective data was collected on 58 patients having neurosurgery in the sitting position in one institution. The incidence of venous air embolism was 43% (25/58), of which the majority were small or moderate in size. There were no episodes of paradoxical air embolism. The incidence of other intraoperative and postoperative complications was low. There was no mortality or serious morbidity. With a proper understanding of the pathophysiology of venous air embolism and the use of sensitive monitoring, anaesthesia for sitting position neurosurgery can be provided safely.
PMID: 15973915 [PubMed - indexed for MEDLINE]
Unexpectedly high block following epidural catheter placement under direct vision: a case report.
D'agapeyeff A, Crabb IJ.
Department of Anaesthetics, Gloucestershire Royal Hospital, Gloucester, United Kingdom.
A 72-year-old female underwent elective lumbar spinal decompression. At the end of the procedure an epidural catheter was sited by the surgeon under direct vision. A bolus of levobupivacaine was injected. Shortly after reaching the recovery area, the patient collapsed and required re-intubation and mechanical ventilation. She was extubated five hours later and suffered no adverse sequelae. Having excluded other possible causes of immediate post-operative collapse, a clinical diagnosis of subdural blockade was made. A literature search using Medline has found no other case reports of such a complication following epidural placement under direct vision.
Publication Types:
PMID: 15957703 [PubMed - indexed for MEDLINE]
Spinal-induced hypotension in elderly patients with hip fracture. A comparison of glucose-free bupivacaine with glucose-free bupivacaine and fentanyl.
Martyr JW, Stannard KJ, Gillespie G.
Department of Anaesthesia, Royal Perth Hospital, Perth, Western Australia.
Intraoperative hypotension is a common and potentially deleterious event in elderly patients undergoing spinal anaesthesia for repair of hip fractures. The synergism between intrathecal opioids and local anaesthetics may allow a reduction in the dose of local anaesthetic and cause less sympathetic block and hypotension, while still maintaining adequate anaesthesia. We studied 40 elderly patients having either an insertion of a dynamic hip screw or a hemiarthroplasty and compared 9.0 mg glucose-free bupivacaine with added fentanyl 20 microg (group BF) with 11.0 m glucose-free bupivacaine alone (group B). Hypotension was defined as a fall in systolic blood pressure to less than 75% baseline or less than 90 mmHg. The incidence and frequency of hypotension in group BF were less than in group B. Similarly, falls in systolic, diastolic and mean blood pressures were all less in group BF than in group B. However, there were four failed blocks in group BF and one in group B.
Publication Types:
PMID: 15957693 [PubMed - indexed for MEDLINE]
Bifocal tuberculosis highlighted by obstetric combined spinal-epidural analgesia.
Morau EL, Lotthe AA, Morau DY, Parneix M, Hocquet AF, Colson PH.
Publication Types:
PMID: 16052132 [PubMed - indexed for MEDLINE]
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A lesson learned.
Todd MM.
Publication Types:
PMID: 16052129 [PubMed - indexed for MEDLINE]
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Changes in arterial pressure during mechanical ventilation.
Michard F.
Department of Anesthesia and Critical Care, Massachusetts General Hospital-Harvard Medical School, Boston, Massachusetts, USA. michard.frederic@free.fr
Mechanical ventilation induces cyclic changes in vena cava blood flow, pulmonary artery blood flow, and aortic blood flow. At the bedside, respiratory changes in aortic blood flow are reflected by "swings" in blood pressure whose magnitude is highly dependent on volume status. During the past few years, many studies have demonstrated that arterial pressure variation is neither an indicator of blood volume nor a marker of cardiac preload but a predictor of fluid responsiveness. That is, these studies have demonstrated the value of this physical sign in answering one of the most common clinical questions, Can we use fluid to improve hemodynamics?, while static indicators of cardiac preload (cardiac filling pressures but also cardiac dimensions) are frequently unable to correctly answer this crucial question. The reliable analysis of respiratory changes in arterial pressure is possible in most patients undergoing surgery and in critically ill patients who are sedated and mechanically ventilated with conventional tidal volumes.
Publication Types:
PMID: 16052125 [PubMed - indexed for MEDLINE]
Comment in:
Deliberate perioperative systems design improves operating room throughput.
Sandberg WS, Daily B, Egan M, Stahl JE, Goldman JM, Wiklund RA, Rattner D.
Harvard Medical School, Boston, Massachusetts, USA. wsandberg@partners.org
BACKGROUND: New operating room (OR) design focuses more on the surgical environment than on the process of care. The authors sought to improve OR throughput and reduce time per case by goal-directed design of a demonstration OR and the perioperative processes occurring within and around it. METHODS: The authors constructed a three-room suite including an OR, an induction room, and an early recovery area. Traditionally sequential activities were run in parallel, and nonsurgical activities were moved from the OR to the supporting spaces. The new workflow was supported by additional anesthesia and nursing personnel. The authors used a retrospective, case- and surgeon-matched design to compare the throughput, cost, and revenue performance of the new OR to traditional ORs. RESULTS: For surgeons performing the same case mix in both environments, the new OR processed more cases per day than traditional ORs and used less time per case. Throughput improvement came from superior nonoperative performance. Nonoperative Time was reduced from 67 min (95% confidence interval, 64-70 min) to 38 min (95% confidence interval, 35-40 min) in the new OR. All components of Nonoperative Time were meaningfully reduced. Operative Time decreased by approximately 5%. Hospital and anesthesia costs per case increased, but the increased throughput offset costs and the global net margin was unchanged. CONCLUSIONS: Deliberate OR and perioperative process redesign improved throughput. Performance improvement derived from relocating and reorganizing nonoperative activities. Better OR throughput entailed additional costs but allowed additional patients to be accommodated in the OR while generating revenue that balanced these additional costs.
PMID: 16052124 [PubMed - indexed for MEDLINE]
[Evaluation of continuous nerve block for postoperative pain management in orthopaedic surgery]
[Article in French]
Compere V, Cornet C, Fourdrinier V, Maitre AM, Duparc F, Biga N, Dureuil B.
Departement d'anesthesie-reanimation, CHU de Charles-Nicolle, 1, rue de Germont, 76000 Rouen, France. vincentcompere@hotmail.com
OBJECTIVE: After orthopaedic surgery, continuous nerve block analgesia provides effective postoperative pain relief. The practical use of these techniques may present problems. The purpose of this study was to assess the development of continuous block procedure for postoperative pain based on quality standard management and the effectiveness of initial training as an adjunct for introduction of these techniques. MATERIALS AND METHODS: A staff committee of anaesthesiologists established a specific practical working protocol. The medical and paramedical teaching sessions were immediately evaluated using a questionnaire. RESULTS: 214 consecutive patients were included. The incidence of side effects and complications were higher in the beginning of protocol. Constant improvement of these results was observed throughout the study. The rate patients with pain were 10%. The analysis of medical evaluation should permit to determine an acceptable level of quality. Most patients were satisfied with their management. CONCLUSION: Pain management quality assurance program provided an improvement in efficacy of postoperative pain management in our protocol. Further, evaluation may be required to assess the complete benefits of this new protocol as regards postoperative pain.
PMID: 15949910 [PubMed - indexed for MEDLINE]
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[About three consecutive pregnancies in a patient suffering from liver cirrhosis]
[Article in French]
Bonnin M, Roman H, Bolandard F, Canis M, Bazin JE.
Departement d'anesthesie-reanimation, polyclinique, Hotel-Dieu, CHU de Clermont-Ferrand, 63000 Clermont-Ferrand, France. mbonnin@chu-clermontferrand.fr
We report the case of a patient suffering from an immune liver cirrhosis with chronic liver insufficiency and a portal hypertension, presenting with three consecutive pregnancies. During the first pregnancy, stillbirth occurred at 34 weeks gestation (WG) with a justified vaginal delivery. There was no liver deterioration during the second pregnancy until 36 WG when fetal distress occurred, requiring a caesarean section under general anaesthesia. During the third pregnancy, fetal distress and maternal hepatic failure occurred at 35 WG, requiring an emergency caesarean section complicated with post partum haemorrhage and an episode of encephalopathy.
Publication Types:
PMID: 15922544 [PubMed - indexed for MEDLINE]
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[Iliofascial block in prehospital for a quadriceps tendon rupture]
[Article in French]
Burnod A, Duchateau FX, Legoff S, Juvin P, Mantz J.
Publication Types:
PMID: 15922543 [PubMed - indexed for MEDLINE]
Comment on:
Ropivacaine cardiac toxicity--not as troublesome as bupivacaine.
[Article in English, French]
Finucane BT.
Publication Types:
PMID: 15872119 [PubMed - indexed for MEDLINE]
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Effects of electroacupuncture on expression of somatostatin and preprosomatostatin mRNA in dorsal root ganglions and spinal dorsal horn in neuropathic pain rats.
Dong ZQ, Xie H, Ma F, Li WM, Wang YQ, Wu GC.
Department of Integrative Medicine and Neurobiology, Institute of Acupuncture Research, Shanghai Medical College, Fudan University, P.O. Box 291, 138, Yi Xue Yuan Road, Shanghai 200032, China.
Somatostatin (SOM) is an endogenous non-opioid neuropeptide that has analgesic effect in rodents and human beings. Previous studies indicated that SOM might be involved in the modulating effects of electroacupuncture (EA). Using immunohistochemistry and RT-PCR, the present study observed the effects of EA on the expression of SOM peptide and preprosomatostatin (ppSOM) mRNA in a rat model of neuropathic pain induced by chronic constriction injury (CCI) to the sciatic nerve. No significant change was detected in the expression of SOM and ppSOM mRNA following CCI. However, EA could significantly enhance SOM expression in dorsal root ganglion (DRG) and spinal dorsal horn as well as ppSOM mRNA level in DRG of neuropathic pain rats. The present data demonstrated that EA could activate endogenous SOM of neuropathic pain rats and this might be one of the mechanisms that underlie the effectiveness of EA in the treatment of neuropathic pain.
PMID: 15970377 [PubMed - indexed for MEDLINE]
Comment on:
Unilateral tremor of the upper and lower limb after an axillary brachial plexus block.
Zeidan AM.
Publication Types:
PMID: 15898038 [PubMed - indexed for MEDLINE]
Comment on:
Re: combination of intraneural injection and high-injection pressure leads to fasicular injury and neurologic deficits in dogs.
Selander DE.
Publication Types:
PMID: 15898037 [PubMed - indexed for MEDLINE]
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A modified approach to transcrural celiac plexus block.
Yang IY, Oraee S.
Department of Anesthesiology and Pain Medicine, Bronx-Lebanon Hospital Center, Our Lady of Mercy Medical Center, Bronx, NY, USA. iyangmd@yahoo.com
OBJECTIVES: Transcrural celiac block using the needle "walking off" the L1 vertebra technique may cause complications. We used patient-specific computed tomography (CT) images as a roadmap to perform the block under fluoroscopy. We present 1 case to describe the technique. CASE REPORT: The patient is a 63-year-old woman with refractory pain from pancreatic cancer. Her CT showed the celiac trunk at the upper L1 vertebra and 2 cm left to the midline. Needle trajectories were drawn on that film. The line representing the classic "walking off" the bone technique on the left side crossed the aorta. Two lines targeting the base of the celiac trunk were modified, thereby avoiding both the L1 vertebra and the surrounding organs. The following were measured: the distance from the midline to the left needle entry (2.5 cm), the angle for the left needle insertion (90 degrees), the distance (6 cm) and the angle (65 degrees) for the right needle entry, and the distance from the anterior margin of the L1 to the celiac trunk (2.6 cm). During the procedure, 2 needles were placed according to these measurements in a plane superior to the transverse process of the L1. No bony contact or needle redirection was made. Both needles reached 3 cm anterior to the anterior margin of the L1. X-ray contrast crossed the midline and silhouetted the target vasculature. Five milliliters of 0.2% ropivacaine followed by 10 mL of 6% phenol were injected on each side. The patient's pain level improved to 0 to 1/10 on a visual analog scale. CONCLUSIONS: The modified technique avoided painful needle contact on the bone, reduced needle redirections, and decreased the possibility of vital organ puncture.
Publication Types:
PMID: 15898036 [PubMed - indexed for MEDLINE]
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Clinical efficacy of the brachial plexus block via the posterior approach.
Sandefo I, Iohom G, Van Elstraete A, Lebrun T, Polin B.
Department of Anesthesiology, Clinique Saint Paul, Fort de France, Martinique, France. ignacesandefo@hotmail.com
BACKGROUND AND OBJECTIVES: The posterior approach to the brachial plexus remains underused. We assessed the clinical effectiveness of this technique for shoulder surgery. METHODS: One hundred eighty-seven consecutive patients scheduled to undergo shoulder surgery were assessed after a single-injection nerve-stimulation technique using ropivacaine 0.75%. Sensory and motor block was evaluated in the distribution area of each terminal branch of the brachial plexus every 10 minutes for 30 minutes. Postoperative analgesia was evaluated at regular time intervals at rest and with passive movement, up to 24 hours postoperatively. RESULTS: The brachial plexus was reached at a depth of 6.5 +/- 0.9 cm. One attempt was sufficient in 85% of patients. Neck pain during insertion of the needle was encountered in 6 (3%; 95% confidence interval [CI], 0.7%-5.6%) patients. Thirty minutes after ropivacaine injection, the axillary, radial, median, musculocutaneous, and ulnar nerves were anesthetized in 100%, 100%, 97%, 96%, and 68% of cases, respectively. The success rate of the block was 98%. Postoperative analgesia was satisfactory in 97% of patients up to 12 hours after the initial injection. Dysphonia and Horner's syndrome were observed in 14 (7%; 95% CI, 3.7%-11.2%) and 12 (6%; 95% CI, 2.9%-9.9%) patients, respectively. One patient (0.5%; 95% CI, 0%-1.5%) had documented hemidiaphragmatic paresis. No complication was noted during the 3-month follow-up period. CONCLUSIONS: This study reports the clinical effectiveness of the single-injection nerve-stimulation technique for the brachial plexus block via the posterior approach in patients undergoing shoulder surgery. It appears to be effective, relatively safe, and well tolerated.
Publication Types:
PMID: 15898026 [PubMed - indexed for MEDLINE]
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