Bruce F. Cullen

Correlation of Endotracheal Tube Size with Sore Throat and Hoarseness Following General Anesthesia

Correlation of Endotracheal Tube Size with Sore Throat and Hoarseness Following General Anesthesia DAVID STOUT;MICHAEL BISHOP;JOCHEN DWERSTEC;BRUCE CULLEN; Anesthesiology

Lymphocyte transformation and changes in leukocyte count: effects of anesthesia and operation.

The transformation of lymphocytes in response to phytohemagglutinin stimulation was investigated in 77 patients undergoind anesthesia with and without coincident surgical operation. A depression of lymphocyte transformation apparent immediately following major operations was related primarily to the extent of tissue trauma and not to the anesthetic agent or technique. No depression of lymphocyte transformation followed anesthesia for treatment of pain or for minor operations. The total leukocyte count increased following general anesthesia for prolonged, traumatic operations, primarily because of an influx of neutrophils into the circulation. The leukocyte count did not increase after comparable operations performed with regional anesthesia. Postoperative depression of lymphocyte transformation is primarily due to nonspecific stress, perhaps because of associated sympathetic and adrenocortical stimulation. The depressant effect of anesthesia alone is minimal.

Local Anesthetic Inhibition of Phagocytosis and Metabolism of Human Leukocytes

The effects of lidocaine on latex-particle phagocytosis and the metabolism of normal human leukocytes in citro were determined. A dose-dependent inhibition of nitroblue tetrazolium dye reduction which ranged from 8 per cent with less than 0.05 per cent lidocaine to 50 per cent with more than 0.45 per cent lidocaine was observed. Latex-stimulated leukocytic oxygen consumption was 59 per cent of control with 0.1 per cent lidocaine and 18 per cent of control with 0.5 per cent lidocaine. Lidocaine in concentrations of 0.1 per cent or more caused more than 50 per cent reduction in the number of cells engulfing latex. Leukocytic viability was impaired when cells were incubated with 0.5 per cent lidocaine for more than 30 minutes. Lidocaine therefore interferes with normal function of cells fundamental in defense against infection.

Cardiac dysrhythmias associated with the intravenous administration of ondansetron and metoclopramide

A 37-yr-old woman who had injured her leg several months earlier presented for advancement of a thigh flap. Her only medication was occasional oxycodone. She occasionally smoked and drank alcohol. She was ambulatory and denied significant pulmonary or cardiac disease. She received several general anesthetics after her injury. The only complication was severe postoperative nausea and vomiting treated with ondansetron and metoclopramide. Her physical examination was unremarkable, and her only laboratory abnormality was a hematocrit level of 24%. Because of the patient’s history of postoperative nausea and vomiting, she received ondansetron (4.0 mg) and metoclopramide (10.0 mg) IV in the preoperative holding area. En route to the operating room, she complained of feeling lightheaded and nauseated and of having a headache. She vomited once. After she was assisted onto the operating room table, an electrocardiogram (ECG) monitor showed bigeminy, which converted spontaneously to a sinus rhythm within 10 s. Arterial blood pressure (BP) was normal. Subsequently, the ECG showed marked ST segment depression. Coincidentally, the patient complained of chest heaviness and a tightness in her throat. Oxygen was administered by mask, and fentanyl 25 pg was given IV. A 12-lead ECG revealed T-wave inversion with ST segment depression on the inferior, anterior, and lateral leads. BP remained normal. The procedure was canceled, and the patient’s symptoms and ECG abnormalities resolved within 5 min without further intervention. She was admitted to a cardiac unit and

Clinical Signs of Anesthesia

The clinical signs of anesthetic depth (heart rate, mean arterial pressure, pupil diameter, pupil reactivity to light, tearing, and eye movement) were correlated with anesthetic dose in healthy young volunteers. During halothane, halothane—nitrous oxide, Forane, or Forane–nitrous oxide anesthesia at normal PaCO2 (controlled ventilation), only hypotension in the first hour of anesthesia correlated with anesthetic dose. After five hours of halothane or halothane–nitrous oxide, blood pressure remained constant as anesthetic concentration increased. During cyclopropane, diethyl ether, and fluroxene anesthesia, only pupillary dilatation and reduced pupil reactivity to light correlated with anesthetic dose. When nitrous oxide was added to halothane, ether, or fluroxene, mean arterial pressure rose and pupils dilated. During halothane–oxygen anesthesia with spontaneous ventilation, the rise in PaCO2 allowed less hypotension and increased heart rate. Tidal volume decreased and respiratory rate increased as anesthesia deepened. During Forane–oxygen anesthesia with spontaneous respiration, mean arterial pressure, tidal volume, and minute ventilation decreased as anesthesia deepened. In healthy surgical patients anesthetized with halothane or Forane only, incision of the skin modified the clinical signs significantly. While surgery continued, this change in clinical signs persisted during Forane anesthesia, but returned to control during halothane anesthesia.

Objective Evaluation of Clinical Performance and Correlation with Knowledge

In certifying competence of anesthesiologists who have finished residency training, knowledge and judgment are evaluated objectively using written and oral examinations. Clinical motor skills, however, are not routinely assessed by objective techniques. This implicitly assumes that knowledge and judgment correlate with performance of motor skills. This study was designed to evaluate whether performance of a particular motor skill correlates with performance on a knowledge test related to that skill. To do this, we developed a criterion-referenced Spinal Anesthesia Skill Test and a knowledge test using multiple-choice questions related to spinal anesthesia. Both the skill and knowledge tests were administered to 44 residents at various levels of training at five major anesthesia teaching programs. Scores on the skill test were significantly higher than in the knowledge test, suggesting that proficiency in this essential motor skill is achieved earlier in training. There was no correlation between scores on the skill test and knowledge test. There were institution-linked differences in the scores on the skill test, suggesting that teaching of motor skills is not uniform. The advantages of developing criteria of performance of motor skills is discussed.

Antacid aspiration in rabbits: a comparison of Mylanta and Bicitra.

The effects of aspiration of (a) 2 ml of Mylanta (a particulate antacid) mixed with 2 ml of hydrochloric acid < pH 1.5), (b) 2 ml of half-strength Bicitra (a soluble antacid) mixed with 2 ml of hydrochloric acid (pH 1.5), (c) 4 ml of hydrochloric acid (pH 1.5), and (d) 4 ml of normal saline (pH 6.5) on arterial blood gas tensions and lung pathology were compared in anesthetized rabbits. Pao2 decreased similarly in all animals 15 minutes after aspiration, but recovered to normal levels 4 hours after aspiration of saline and 48 hours after aspiration of Bicitra. Pao2 remained depressed after aspiration of Mylanta and HCI. Gross and microscopic evidence of lung injury was most severe in animals that aspirated Mylanta. One animal died 8 hours after aspiration of Mylanta.

Resident work hours

Purpose of review The Accreditation Council for Graduate Medical Education has mandated new requirements for work hours for all US resident physicians that became effective in July 2003. Member countries of the European Union are also implementing a reduction in work hours for trainee physicians as per the European Work Time Directives. The following review provides a summary of the basis of limiting work hours for residents, steps taken towards limiting the working hours for resident doctors, and implications to residents, institutions, and states. Recent findings Reduction of work hours for physicians in training is a much awaited and necessary change. Though the framework for such a reduction is in place in most countries, implementation of the policies has been slow thus far, mainly due to financial and manpower constraints. Setting of deadlines for compliance and legislation to penalize the defaulting institutions and programs may help to put the recommendations on work hours into practice. Summary Long work hours contribute to stress, fatigue, and mood changes in trainee physicians that are potentially deleterious to the physician and patients. Recommendations have been made across the globe to reduce resident doctor work hours and legislation is in place to monitor institutional compliance with these recommendations. Once these regulations are complied with, follow-up studies will be needed to evaluate their effects on physician well-being and patient care.

Inhibition of cell-mediated cytotoxicity by halothane and nitrous oxide.

Killing of tumor cells by lymphoid cells is important in cell-mediated immunity and defense against cancer. The authors determined that halothane, in vitro, inhibits the killing of YAAC-1 ascites tumor cells from A/jax mice by sensitized peritoneal exudate cells from C57/Black/6 mice. Lysis of tumor cells was quantitated by release of 51Cr into the culture medium. Inhibition of cell-mediated cytotoxicity ranged from 3 per cent in 0.5 per cent halothane to 44.7 per cent in 2.5 per cent halothane and was related to the duration of halothane exposure. A 12 per cent inhibition of cytotoxicity by 80 per cent nitrous oxide was not statistically significant, but was of a magnitude near that of an equipotent concentration of halothane. The inhibition of cytotoxicity by halothane and nitrous oxide observed in vitro may partially account for the inhibition of cytotoxicity observed when patients undergo surgical operation.

Drug interactions and anesthesia: a review.

HE AVERAGE patient may receive eight differT ent drugs during a hospitalizati~n‘~*~ and an additional five to 10 drugs during anesthesia. A knowledge of the possible interactions between these drugs is essential for the safe conduct of anesthesia. Although several reviews on this subject have appeared,’@ 16. 29. 61 the introduction of new drugs and the realization of previously unrecognized interactions makes an updated discussion necessary. The intent of this article is not to be a comprehensive survey of all drug interactions, but rather a useful review of common drugs and problems for the practicing clinician.