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Addition of fentanyl to bupivacaine prolongs anesthesia and analgesia in axillary brachial plexus block.

Background and Objectives To evaluate the analgesic and anesthetic effects of 40 mL bupivacaine 0.25%, 40 mL bupivacaine 0.25% plus fentanyl 2.5 μg/mL, and 40 mL bupivacaine 0.125% plus fentanyl 2.5 μg/mL for axillary brachial plexus block. Methods Sixty patients were randomly allocated to 3 groups and received axillary brachial plexus block with 40 mL bupivacaine 0.25% (group B), 40 mL bupivacaine 0.25% with fentanyl 2.5 μg/mL (group BF), or 40 mL bupivacaine 0.125% with fentanyl 2.5 μg/mL (group DBF). The onset times and the duration of sensory and motor blocks, duration of analgesia, hemodynamic parameters, and adverse events were noted. Results The mean duration of sensory block and analgesia were longer in group BF (10.1 hours and 20.9 hours) than group B (6.9 hours and 11.6 hours) and DBF (5.9 hours and 12.0 hours) (P < .01, P < .001, respectively). The mean duration of motor block was also longer in group BF (10.7 hours) than group B (4.9 hours) (P < .01). Only 2 patients experienced motor block in group DBF. The frequency of successful block was 35% in group DBF (P < .01). Hemodynamic parameters were similar in all groups. In group B, only 1 patient experienced dizziness. Nausea was observed in 1 patient in each fentanyl group. Conclusion The addition of 100 μg/mL fentanyl to 0.25% bupivacaine almost doubles the duration of analgesia following axillary brachial plexus block when compared with 0.25% bupivacaine alone.

Awake tracheal intubation through the intubating laryngeal mask airway in a patient with halo traction.

PurposeTo report a case of awake tracheal intubation through the intubating laryngeal mask airway (ILMA) in a patient with halo traction.Clinical featuresA 16-yr-old, 40 kg, boy with atlanto-occipital instability and halo traction was scheduled for surgery under general anesthesia. The head of the patient was fixed in a position of flexion and extension was impossible. Cranial magnetic resonance imaging revealed that pharyngeal and laryngeal axes were aligned, but that the oral axis was in an extreme divergent plane. The tongue and oropharynx were anesthetized with 10% lidocaine spray and bilateral superior laryngeal nerve blockade was performed. Under sedation, awake orotracheal intubation via ILMA was successful. Fibreoptic bronchoscopy has been recommended for awake tracheal intubation in such patients. Other techniques, such as use of the Bullard laryngoscope have been described also but awake tracheal intubation through the ILMA in patients with a halo devicein situ has seldom been reported in the medical literature.ConclusionAirway management of patients with cervical spine instability includes adequate preoperative evaluation of the airway and choosing the appropriate intubation technique. We suggest that the ILMA may be an adequate alternative for awake tracheal intubation in patients with an unstable cervical spine and cervical immobilization with a halo device.RésuméObjectifRapporter un cas d’intubation endotrachéaie vigiie au travers du masque iaryngé d’intubation (MLI) chez un patient avec un halo en traction.Éléments cliniquesUn garçon de 16 ans, pesant 40 kg, présentait une instabiiité atlanto-occipitale et portait un haio en traction. Il devait subir une intervention chirurgicaie sous anesthésie généraie. Sa tête a été immobiiisée en position de flexion, L’extension était impossible. Lexamen du crâne par résonance magnétique a montré l’alignement des axes du pharynx et du larynx, mais un plan très divergent pour l’axe buccal. La langue et l’oropharynx ont été anesthésiés avec une pulvérisation de lidocaïne à 10 % et un blocage du nerf laryngé supérieur bilatéral a été réalisé. L’intubation orotrachéale vigile au travers du MLI a été réussie sous sédation. La fibroscopie bronchique est recommandée pour l’intubation trachéale vigile chez ce type de patients. D’autres techniques, comme l’usage du laryngoscope de Bullard sont aussi décrites, mais l’intubation trachéale vigile au travers du MU chez des patients à qui on a installé un halo en traction in situ a rarement été mentionnée.ConclusionLa prise en charge des voies aériennes de patients souffrant d’instabilité de la colonne cervicale comprend l’évaluation préopératoire complète des voies aériennes et le choix d’une technique d’intubation appropriée. Le MLI semble un choix valable pour l’intubation trachéale vigile dans les cas d’instabilité de la colonne cervicale et d’immobilisation cervicale avec un appareil en halo.

Comparison of Neonatal Effects of Epidural and General Anesthesia for Cesarean Section

We assessed the influence of anesthetic technique for cesarean section on neonatal outcome. Thirty parturient women (ASA I/II) were randomly allocated into two groups. In Group GA general anesthesia was induced with 4 mg·kg–1 thiopental and 1.5 mg·kg–1 succinylcholine. In group EA epidural anesthesia was performed with 20 ml 0.375% bupivacaine through L3–4 inter-space. 1-min Apgar scores were significantly higher in group EA (p < 0.001). Neurologic and Adaptive Capacity scores at 2 and 24 h were higher in group EA (p < 0.001). In terms of blood gas values, umbilical arterial pH and pO2 values were higher in group EA (p < 0.05 and p < 0.001, respectively). The first breast-feeding intervals were found to be shorter in group EA (p < 0.001). We conclude that in terms of better Apgar and NAC scores, acid-base status and earlier initiation of breast-feeding, the epidural anesthesia may be preferred to general anesthesia in cesarean section.

Subdural hematoma as a late complication of spinal anesthesia.

Subdural hematoma is a rare complication of spinal anesthesia. This patient underwent bilateral inguinal herniorrhaphy under spinal anesthesia 40 days prior to admission. Two days after spinal anesthesia, the patient described a typical postdural puncture headache. Oral analgesics, fluid therapy, and lying flat were recommended. Because of prolonged headache, computed tomography scan was performed and demonstrated chronic subdural hematoma in the left fronto-temporo-parietal region. After surgical drainage, the patient fully recovered. Prolonged headache should be regarded as a warning sign of subdural hematoma.

Effects of Menstrual Cycle on Postoperative Analgesic Requirements, Agitation, Incidence of Nausea and Vomiting after Gynecological Laparoscopy

Background: Several studies have suggested that the menstrual cycle has an impact on postoperative nausea and vomiting (PONV). No previous study has evaluated the effect of the menstrual cycle on the incidence of postoperative agitation and analgesic/antiemetic requirements. Methods: On the basis of the phase of the menstrual cycle [pre±menstrual (Pd 25–6), early follicular phase (Pd 8–12), ovulatory phase (Pd 13–15), and luteal phase (Pd 20–24)], 67 patients enrolled in this blinded, prospective study. Anesthesia was standardized. Fentanyl was given to the patients who had severe pain in the recovery room. The patients who had agitation were given midazolam. When pain intensity was >5 on the Visual Analog Scale, metamizol was administered in the Gynecology Department. A blinded anesthesiologist recorded episodes of PONV in the recovery room, and 2 and 24 h postoperatively. Results: The opioid requirement and the frequency of agitation were similar in each group. Metamizol consumption was highest in the luteal phase (p < 0.05). The follicular and luteal phases were predictors for vomiting at recovery (p < 0.05 and p < 0.001, respectively). At the postoperative 2nd hour, nausea was higher in the follicular phase than in the other phases (p < 0.05) and the luteal phase was a predictor for retching (p < 0.001). At the postoperative 24th hour, nausea was the common symptom in the luteal phase (p < 0.05). The need for ondansetron was highest in the luteal phase (p < 0.01). Conclusions: In conclusion, we suggest that the scheduling of all surgical procedures according to the menstrual phase may serve to reduce the incidence of PONV and metamizol/ondansetron consumption and hospital costs.

Brachial plexus injury during subclavian vein catheterization for hemodialysis

Although the subclavian vein is often used for placement of double-lumen hemodialysis catheters, the risk factors for complications for the patients with chronic renal failure are underestimated. We report a case of a patient with chronic renal failure in whom brachial plexus injury was caused by both a compressive hematoma and direct insertion of a needle resulting from a subclavian vein catheterization attempt for hemodialysis. This case emphasizes the need for determining the coagulation status of the patient especially with chronic renal failure before performing invasive procedures.

Comparison of fentanyl–bupivacaine or midazolam–bupivacaine mixtures with plain bupivacaine for caudal anaesthesia in children

Summary Background: The aim of this study was to evaluate the intensity and effectiveness of 0.75 ml·kg−1 bupivacaine 0.25% with the addition of fentanyl or midazolam for caudal block in children undergoing inguinal herniorrhaphy.

Prolonged apnea following succinylcholine administration in undiagnosed acute organophosphate poisoning

Organophosphates (OP) are irreversibly bound to cholinesterase, causing deactivation of acetylcholinesterase. As a result of inhibition of plasma cholinesterase, increased sensitivity to drugs hydrolyzed by this enzyme can occur, e.g. succinylcholine and mivacurium. A case of more prolonged succinylcholine‐induced paralysis in a child with undiagnosed acute OP insecticide poisoning is presented. A 7‐h period of apnea and paralysis after administration of succinylcholine was attributed to the decreased rate of succinylcholine metabolism resulting from inhibition of pseudocholinesterase by the insecticide. In seven previously reported cases of prolonged succinycholine apnea after OP poisoning, exposure to insecticide was in chronic or subacute form without any obvious symptoms, and the duration of apnea did not extend up to 4 h, whereas in our case with acute, severe poisoning, succinylcholine led to more prolonged muscle paralysis. In the anesthetic management of patients with acute OP poisoning, succinylcholine should be avoided.

Acute normovolemic hemodilution and nitroglycerin-induced hypotension: comparative effects on tissue oxygenation and allogeneic blood transfusion requirement in total hip arthroplasty.

STUDY OBJECTIVES To study the comparative effects of acute normovolemic hemodilution and nitroglycerin-induced hypotension on tissue oxygenation and blood transfusion requirement. DESIGN Prospective, randomized study. PATIENTS 30 ASA physical status I and II patients scheduled for primary total hip arthroplasty. INTERVENTIONS Patients were randomized to one of three groups of 10 patients each, to receive acute normovolemic hemodilutin (Group 1) or nitroglycerin-based hypotension (Group 2); Group 3 served as the control group. In Group 1, 2 U of blood was collected and replaced with an equal volume of hydroxyethyl starch (200/0.56%) immediately after anesthesia induction. In Group 2, nitroglycerin was infused at a rate sufficient to reduce mean arterial pressures to 60 to 65 mmHg before initiation of surgery. When hematocrit was reduced to 25%, at first autologous blood and then, if necessary, allogeneic blood was transfused to Group 1, and allogeneic blood was transfused to the other two groups, until hematocrit reached 30% for 5 days postoperatively. MEASUREMENTS AND MAIN RESULTS Total transfused allogeneic units of blood were determined by the fifth postoperative day. Arterial oxygen content (CaO2), venous oxygen content (CvO2), and oxygen extraction ratios (EO2) were calculated by standard formulas. The mean allogeneic transfusion requirement was significantly lower in Group 1 (1.3 +/- 0.8 U) than in Group 2 (2.3 +/- 0.8 U) or Group 3 (2.7 +/- 1.1 U) (p < 0.05). In Group 1, CaO2 and CvO2 were decreased at all times, but EO2 was significantly increased from 15 +/- 3.9% to 33.3 +/- 5.3% (p < 0.001). As for the other two groups, although CaO2 and CvO2 were decreased, EO2 was not significantly increased. CONCLUSIONS Acute normovolemic hemodilution is more effective than nitroglycerin-induced hypotension in reducing allogeneic blood transfusion requirement in total hip replacement surgery, without significant metabolic changes.

Behavioural effects of chronic exposure to sub-anesthetic concentrations of halothane, sevoflurane and desflurane in rats

BackgroundA double-blind, randomized trial was conducted to determine the behavioural effects of chronic exposure to subanesthetic concentrations of halothane, sevoflurane and desflurane in rats.MethodsHalothane, sevoflurane and desflurane group rats received 0.1%, 0.3%, and 0.6% concentrations in a flow rate of 3 L·min-1 O2, respectively. Control animals also received 3 L·min-1 O2 in another investigation room, which had the same properties as the study group rooms. Rats breathed inhaled agents or oxygen between 09:00-13:00 hr every day for 30 days. After 30 days of inhalation of subanesthetic doses of inhaled agents or oxygen, behavioural tests were applied.ResultsTests of exploratory activity and curiosity (hole-board test), anxiety (elevated plus maze test) and learning and memory functions (multiple T maze test), demonstrated that chronic exposure to subanesthetic concentrations of all three anesthetics alters behavioural functions in rats. However, impairment of learning (P<0.05) and memory function (P<0.05) were greater in association with desflurane, in comparison to halothane and sevoflurane-treated rats.ConclusionChronic exposure to subanesthetic concentrations of halothane, sevoflurane and desflurane is associated with behavioural change in rats. Of the three drugs, desflurane was associated with the lowest learning and memory function test scores.RésuméObjectifDéterminer, par une étude randomisée à double insu, les effets comportementaux de l’exposition chronique à des concentrations sous-anesthésiques d’halothane, de sévoflurane et de desflurane chez les rats.MéthodeĽhalothane, le sévoflurane et le desflurane ont été administrés à des groupes de rats selon des concentrations respectives de 0,1 %, 0,3 % et 0,6% à un débit 3 L·min-1 d’O2. Les animaux témoins ont aussi reçu 3 L·min-1 d’O2 dans un local d’expérimentation qui avait les même propriétés que le local du groupe à l’étude. Les rats ont respiré les anesthésiques d’inhalation ou de l’oxygène entre 9 h et 13 h tous les jours, pendant 30 jours. Après quoi, des tests de comportement ont été appliqués. Résultats : Les tests d’activité exploratrice et de curiosité (planche trouée), d’anxiété (test de labyrinthe «elevated plus maze test») et des fonctions cognitive et mnésique («multiple T maze test») ont démontré qu’une exposition chronique à des concentrations sous-anesthésiques des trois agents altèrent les comportements des rats. Ľatteinte cognitive (P < 0,05) et mnésique (P < 0,05) a été plus importante avec le desflurane, comparé à l’halothane et au sévoflurane.ConclusionĽexposition chronique à des concentrations sousanesthésiques d’halothane, de sévoflurane et de desflurane est associée à un changement de comportement chez les rats. Le desflurane a produit les scores les plus bas aux épreuves cognitives et mnésiques.