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Lumbar puncture associated with pneumocephalus: report of a case.
Kozikowski GP, Cohen SP.
Department of Anesthesiology, Pain Management Center, New York University School of Medicine, New York, New York 10016, USA.
Pneumocephalus is a well known complication of spinal and epidural anesthesia, but it is extremely rare after diagnostic or therapeutic lumbar puncture. This uncommonness can obscure the clinical diagnosis and lead to unnecessary procedures and prolonged patient discomfort. We report a 72-yr-old woman with normal pressure hydrocephalus who underwent an unremarkable lumbar puncture that was complicated by a postprocedure pneumocephalus that manifested as a continuous headache. The pneumocephalus resolved spontaneously after 4 days. Possible mechanisms for this occurrence, along with steps that can be taken to prevent this complication, are discussed. IMPLICATIONS: We report a case of symptomatic pneumocephalus in a woman with normal pressure hydrocephalus after an unremarkable lumbar puncture. The possible mechanisms for this occurrence, along with steps that can be taken to prevent this complication, are discussed.
Publication Types:
PMID: 14742399 [PubMed - indexed for MEDLINE]
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Reversal of an unintentional spinal anesthetic by cerebrospinal lavage.
Tsui BC, Malherbe S, Koller J, Aronyk K.
Department of Anesthesiology, University of Alberta, Edmonton, Alberta, Canada. btsui@ualberta.ca
In this case report, we describe the use of cerebrospinal fluid lavage as a successful treatment of an inadvertent intrathecally placed epidural catheter in a 14-yr-old girl who underwent a combination of epidural anesthesia and general anesthesia for orthopedic surgery. In this case, a large amount of local anesthetic was injected (the total possible intrathecal injection was 200 mg of lidocaine and 61 mg of bupivacaine), resulting in apnea and fixed dilated pupils in the patient at the end of surgery. Twenty milliliters of cerebrospinal fluid was replaced with 10 mL of normal saline and 10 mL of lactated Ringer's solution from the "epidural" catheter. Spontaneous respiration returned 5 min later, and the patient was tracheally extubated after 30 min. No signs of neurological deficit or postdural puncture headache were noted after surgery. IMPLICATIONS: Cerebrospinal lavage may be a helpful adjunct to the conventional supportive management of patients in the event of an inadvertent total spinal.
Publication Types:
PMID: 14742383 [PubMed - indexed for MEDLINE]
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The safety and efficacy of a fentanyl patient-controlled transdermal system for acute postoperative analgesia: a multicenter, placebo-controlled trial.
Chelly JE, Grass J, Houseman TW, Minkowitz H, Pue A.
Department of Anesthesiology, University of Pittsburgh Medical Center, Pennsylvania 15261, USA. chelje@anes.upmc.edu
A noninvasive method of delivery of parenteral opioids for management of acute pain may offer logistic advantages for patients and nursing staff. A patient-controlled transdermal system (PCTS) under development consists of a preprogrammed, self-contained drug-delivery system that uses electrotransport technology (E-TRANS, ALZA Corp, Mountain View, CA) to deliver 40 micro g of fentanyl HCl over 10 min per on-demand dose for patient-controlled analgesia (PCA). In this randomized, double-blinded, placebo-controlled trial we compared the efficacy and safety of on-demand fentanyl HCl PCTS 40 microg against placebo for postoperative pain up to 24 h after major abdominal, orthopedic, or thoracic surgery in 205 patients. The primary efficacy measurement was the percentage of patients withdrawn from the study because of inadequate analgesia after completing at least 3 h of treatment. Secondary efficacy measures included mean pain intensity (using visual analog scales), patient global assessments, and investigator global assessments. Of 189 patients considered evaluable for efficacy, 25% of patients in the fentanyl HCl PCTS 40 microg group withdrew because of inadequate analgesia, compared with 40.4% of the placebo group (P < 0.05). Use of fentanyl HCl PCTS 40 micro g was associated with lower VAS scores and higher mean patient and investigator global assessment scores compared with placebo. No patient experienced clinically relevant respiratory depression. This study showed that a fentanyl HCl PCTS 40 microg for PCA was superior to placebo and well tolerated for the control of moderate to severe postoperative pain for up to 24 h after major surgery. IMPLICATIONS: This multicenter, randomized, double-blinded, placebo-controlled trial showed that an on-demand fentanyl HCl patient-controlled transdermal system (PCTS) was superior to placebo and well tolerated for the control of moderate to severe postoperative pain for up to 24 h after major surgery. This fentanyl HCl PCTS is a preprogrammed, needle free, self-contained drug-delivery system that uses electrotransport technology (iontophoresis) to deliver 40 microg of fentanyl per on-demand dose.
Publication Types:
- Clinical Trial
- Multicenter Study
- Randomized Controlled Trial
PMID: 14742382 [PubMed - indexed for MEDLINE]
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Epidural levobupivacaine 0.1% or ropivacaine 0.1% combined with morphine provides comparable analgesia after abdominal surgery.
Senard M, Kaba A, Jacquemin MJ, Maquoi LM, Geortay MP, Honore PD, Lamy ML, Joris JL.
Department of Anesthesia and Intensive Care Medicine, CHU de Liege, Belgium.
Ropivacaine appears attractive for epidural analgesia because it produces less motor block than racemic bupivacaine. The potential benefits of levobupivacaine with regard to motor blockade require further investigations. In this study, we compared the efficacy, dose requirements, side effects, and motor block observed with epidural levobupivacaine and ropivacaine when given in combination with small-dose morphine for 60 h after major abdominal surgery. Postoperatively, 50 patients were randomly allocated, in a double-blinded manner, to patient-controlled epidural analgesia with the same settings and without basal infusion, using 0.1% levobupivacaine or 0.1% ropivacaine. Both were combined with an epidural infusion of 0.1 mg/h morphine. Pain scores, side effects, motor block, and local anesthetic consumption were measured for 60 h. Pain scores measured on a 100-mm visual analog scale were approximately 20 mm at rest and 40 mm during mobilization in both groups. Bromage scores were 1 for all patients after the fourth postoperative hour. Consumption of levobupivacaine and ropivacaine were similar: 344 +/- 178 mg levobupivacaine versus 347 +/- 199 mg ropivacaine 48 h postoperatively. On postoperative day 2, 19 patients in the ropivacaine group versus 12 in the levobupivacaine group were able to ambulate (P < 0.05). No difference was noted concerning incidence of side effects. We conclude that when used as patient-controlled epidural analgesia and combined with small-dose epidural morphine, 0.1% levobupivacaine and 0.1% ropivacaine produce comparable postoperative analgesia with a similar incidence of side effects. IMPLICATIONS: Small concentrations (0.1%) of epidural levobupivacaine and ropivacaine combined with morphine (0.1 mg/h) produce comparable analgesia and have similar side effects for similar dose requirements.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 14742376 [PubMed - indexed for MEDLINE]
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Does a preemptive block of the great auricular nerve improve postoperative analgesia in children undergoing tympanomastoid surgery?
Suresh S, Barcelona SL, Young NM, Heffner CL, Cote CJ.
Northwestern University Feinberg School of Medicine, and Department of Pediatric Anesthesiology, Children's Memorial Hospital, Chicago, Illinois, 60614, USA. ssuresh@northwestern.edu
We performed a double-blinded randomized controlled trial to evaluate the efficacy of preemptive analgesia in children undergoing tympanomastoid surgery. Children were divided into two groups: group block-block (BB) received a preemptive great auricular nerve block (GAN-block) with 0.25% bupivacaine with 1:200,000 epinephrine before incision followed by a second GAN-block with 0.25% bupivacaine with 1:200,000 epinephrine 1 h before the end of the procedure. Group sham block-block (SB-B) received a preemptive GAN-block with normal saline before surgical incision followed by a GAN-block with 0.25% bupivacaine with 1:200000 epinephrine 1 h before the completion of the procedure. All patients were evaluated for pain with the objective pain score (OPS) by a blinded observer. There was no difference in pain rescue requirements in the postanesthesia care unit (BB versus SB-B, 1 of 20 versus 3 of 20, P= 0.60) or in the short-stay unit (BB versus SB-B, 5 of 20 versus 11 of 20, P = 0.107) or for the entire hospital stay (P = 0.20). There was no significant difference between groups in the time to first rescue pain medication (BB versus SB-B, 226 +/- 71 min versus 201 +/- 94 min). There was no significant difference between groups regarding vomiting in the postoperative period (P = 0.52). We conclude that a preoperative GAN-block does not offer significant advantages for postoperative pain relief in children undergoing tympanomastoid surgery. IMPLICATIONS: This double-blinded randomized controlled trial compared the efficacy of preemptive analgesia with a peripheral nerve block of the great auricular nerve for decreasing postoperative pain in children undergoing tympanomastoid surgery. Preemptive analgesia did not improve the quality or duration of postoperative analgesia in our cohort.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 14742364 [PubMed - indexed for MEDLINE]
Coughing can reduce pain of injection, study shows.
Dobson R.
PMID: 14976084 [PubMed - as supplied by publisher]
Editorial III: Opioids for persistent non-cancer pain: recommendations for clinical practice.
Simpson KH.
St James's University Hospital, Leeds LS9 7TF, UK. karen.simpson@dsl.pipex.com
PMID: 14970133 [PubMed - in process]
The effects of protein phosphatase inhibitors on nociceptive behavioral responses of rats following intradermal injection of capsaicin.
Zhang X, Wu J, Fang L, Willis WD.
Department of Anatomy and Neuroscience, Marine Biomedical Institute, The University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555-1069, USA.
The functions of crucial proteins in the nervous system are modulated by kinases and phosphatases which catalyze opposing reactions of phosphorylation and dephosphorylation. During spinal cord central sensitization, serine/threonine protein phosphatase 2A (PP2A) may play an important role in determining the excitability of nociceptive neurons in the spinal cord by modulating the phosphorylation state of some critical proteins. The effects of a general inhibitor of PP2A, okadaic acid (OA), and a specific inhibitor, fostriecin, on the behavioral responses of rats following capsaicin injection were investigated in this study. Hyperalgesia was initiated by injection of capsaicin into the plantar surface of the hindpaw of rats. An intrathecal catheter was previously implanted into the subarachnoid space of the spinal cord for the administration of a variety of drugs. Rats were tested for responses to mechanical stimuli using von Frey filaments of different bending forces applied at a site outside the area of injection. Responses to heat stimuli were detected from a site near the injection area. The responses were recorded before and after injection of capsaicin with the perfusion of ACSF, OA negative control, OA or fostriecin at different time points. The results demonstrated that secondary mechanical hyperalgesia and allodynia can be induced by the intradermal injection of capsaicin. Compared to administration of ACSF or the OA negative control, infusion of the phosphatase inhibitor OA or of fostriecin into the subarachnoid space enhanced the secondary mechanical hyperalgesia and allodynia by making the intradermal capsaicin-induced hyperalgesia and allodynia last longer.
PMID: 14659528 [PubMed - indexed for MEDLINE]
Summary statement: emerging techniques for treatment of degenerative lumbar disc disease.
An H, Boden SD, Kang J, Sandhu HS, Abdu W, Weinstein J.
Emerging techniques for management of degenerative disc disease include modern fusion interbody cage devices, intradiscal electrothermal therapy, and disc prostheses among others. The management of discogenic low back pain is controversial: its accurate diagnosis is difficult, and treatment is inconsistent. Before wide application, the advantages and disadvantages of each procedure must be considered in lieu of inadequate study design and the lack of sufficient long-term outcome studies.
PMID: 12897470 [PubMed - indexed for MEDLINE]
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Intradiscal electrothermal therapy: a treatment option in patients with internal disc disruption.
Biyani A, Andersson GB, Chaudhary H, An HS.
Department of Orthopedic Surgery, Medical College of Ohio, Toledo, Ohio, USA.
STUDY DESIGN: A literature review was conducted. OBJECTIVES: To review the anatomy, pathophysiology, diagnosis, procedure, and clinical results of intradiscal electrothermal therapy (IDET). SUMMARY OF BACKGROUND DATA: Low back pain is a major physical and socioeconomic entity. A significant percentage of low back pain is attributable to internal disc disruption. The management of internal disc disruption has traditionally been limited to either conservative treatment or spinal fusion. IDET has been performed as an alternative to these therapies. METHODS: The available literature was reviewed. RESULTS: Scientific data regarding the pathophysiology, biologic effects, and clinical results are relatively scarce. Early biomechanical and histologic investigations into the effects of IDET are conflicting. However, in early prospective human trials, IDET seems to provide some benefit with little risk. CONCLUSIONS: IDET is potentially beneficial treatment for internal disc disruption in carefully selected patients as an alternative to spinal fusion. More basic science and clinical research with long-term follow-up evaluation is necessary.
Publication Types:
PMID: 12897468 [PubMed - indexed for MEDLINE]
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