David Soroker

Symptomatic hyponatraemia due to inappropriate antidiuretic hormone secretion following minor surgery

A rare case of the syndrome of inappropriate antidiuretic hormone secretion occuring after minor surgery is presented. A ten-year-old, previously healthy boy underwent general anaesthesia for detorsion and right orchiopexy. Throughout the operations, which lasted for one hour, he received 120 ml Ringer’s lactate solution. The immediate postoperative period was uneventful. Twenty-two hours postoperatively he was found unconscious with generalized tonic-clonic seizures. Simultaneously obtained serum sodium concentration (121 mEq · L−1) serum osmolarity (265 mEq · L−1), urine sodium concentration (87 mEq · L−1) and urine osmolarity (525 mEq · L−1) suggested inappropriate antidiuretic hormone secretion which was confirmed by an elevated serum arginine-vasopresin (AVP) level of 14.5 pcg · ml−1 (normal 1–5 pcg · ml−1) measured by radioimmune assay. He was treated with a single iv dose of 30 mg furosemide and fluid restriction, which produced a gradual increase of his serum sodium concentration to normal within two days. He was well during the remainder of his hospitalization.RésuméOn présente un rare cas d’ un syndrome de sécrétion inappropriee d’ hormone antidiurétique survenant après chirurgie mineure. Un enfant en bonne santé âgé de dix ans a subi l’ anesthésie générale pour détorsion et orchiopexie droite. Durant l’opération qui a durée une heure, il a reçu 120 ml de lactate Ringer. La période postopératoire fut sans complication. Vingt-deux heures après l’ opération, l’ enfant fut trouvé inconscient avec. des convulsions généralisées cloniques-toniques. La concentration simultanée de sodium sérique (121 mEq · L−1), l’osmolarité sérique (265 mEq · L−1), la concentration sodique d’ urine (87 mEq · L−1) et l’ osmolarité urinaire (525 mEq · L−1) out suggéré le syndrome de sécrétion inappropriée d’ hormone antidiurétique qui fut confirmé par l’ élévation de la concentration sérique de l’ arginine-vasopressine (AVP) de 14.5 peg · ml−1 (normle 1–5 peg · ml−1) mesurée par radioimmunoessai. Il fut traité par une dose intraveineuse unique de 30 mg de furosémide et la restriction hydrique qui amena graduellement une augmentation de la concentration du sodium sérique a la normale en dedans de deux jours. Il se sentait bien durant de son hospitalisation.

Phenol lumbar sympathetic block in diabetic lower limb ischemia

Background: Patients with arteriosclerotic peripheral vascular disease and lower limb ischemia have painful ulceration or incipient gangrene of the lower limb with intractable rest pain. The arteriosclerotic changes may preclude any surgery other than amputation. Methods: We examined whether chemical sympathectomy could relieve pain, arrest gangrene and postpone amputation, even in diabetic patients. Results: Phenol lumbar sympathectomy was performed on 373 patients, of whom 226 (60.6%) were diabetic. Over 24–120 months of follow-up, 219 patients (58.7%) experienced total relief from pain and healing of gangrenous ulcers, although the treatment was unsuccessful in 154 patients. A favorable result was marked in diabetic patients who had rest pain and in non-diabetic patients who had digital gangrene or digital ulcers. Age and sex did not affect the results but heavy smoking did. Conclusion: Phenol sympathectomy should be considered as an alternative to surgical sympathectomy. Furthermore, the technique may be a precursor to and even an alternative to amputation in patients who have diabetes and advanced arteriosclerosis of the lower limb.

Lidocaine inhalation attenuates the circulatory response to laryngoscopy and endotracheal intubation

STUDY OBJECTIVE To evaluate the effect of lidocaine inhalation on the circulatory response to direct laryngoscopy and endotracheal intubation. DESIGN Prospective, randomized study. SETTING Operating theater at a public hospital. PATIENTS Eighty patients (ASA physical status I and II ages 25 to 45 years) scheduled for major abdominal surgery. INTERVENTIONS In the first stage, 40 patients were randomly assigned to receive inhalation of either lidocaine 40 mg or a 0.9% solution of sodium chloride (placebo). In the second stage, the next 20 consecutive patients received inhalation of lidocaine 120 mg, and another 20 consecutive patients received intravenous (IV) lidocaine 1 mg/kg. MEASUREMENTS AND MAIN RESULTS Mean arterial pressure rose significantly in the i.v. lidocaine group (21.2 mmHg; p < 0.05), the saline inhalation group (29.2 mmHg; p < 0.05), and the lidocaine 40 mg inhalation group (22.9 mmHg; p < 0.05), but not in the lidocaine 120 mg inhalation group (10.1 mmHg). The heart rate (HR) response to intubation with lidocaine inhalation was dose dependent. In the saline inhalation group, HR increased by 15.6 beats per minute (bpm) (p < 0.05); in the lidocaine 40 mg inhalation group, HR increased by 9.1 bpm (p < 0.05); and in the lidocaine 120 mg inhalation group, HR increased by only 3.1 bpm. CONCLUSION Inhalation of lidocaine 120 mg prior to induction of anesthesia is an effective, safe, and convenient method to attenuate the circulatory response to laryngoscopy and endotracheal intubation.

Influence of Epidural Anaesthesia on the Course of Labour in Patients with Antepartum Fetal Death

Summary: The course of labour in 22 patients with antepartum fetal death who received epidural anaesthesia was evaluated as compared to 22 controls matched for parity and gestational age, who received narcotic pain relief. Both groups had similar preinduction cervical dilatation and the induction was performed by amniotomy and oxytocin infusion. The mean first stage of labour was 5.4 hours in the epidural group, and 8.7 hours in the controls (p = 0.0192). The mean cervical dilatation rate was 3.3 cm/hour and 1.0 cm/hour respectively (p = 0.0142). The second stage was similar in both groups. We conclude, that parturients receiving epidural anaesthesia may benefit both emotionally and physically from excellent pain relief and a shorter delivery process when going through the distressing experience of delivering a dead fetus.

Pulse oximetry from the nasal septum

STUDY OBJECTIVE To evaluate the accuracy of the nasal septum site for pulse oximetry measurement of arterial oxyhemoglobin saturation (SpO2) in hypothermic patients. DESIGN Prospective study. SETTING Operating theater of a public hospital. PATIENTS Fourteen hypothermic (temperature 34.6 degrees C to 36 degrees C) patients (eight males and six females) undergoing a major surgical abdominal procedure. INTERVENTIONS Fifty estimations of SpO2 were simultaneously made by a flex sensor probe applied at the nasal septum site and by a finger sensor probe using a pulse oximeter. The results were compared with arterial oxygen saturation (SaO2) as measured by arterial blood gas sampling. MEASUREMENTS AND MAIN RESULTS In 18% of the estimations, the finger probe produced unmeasurable results. The nasal septum probe did not produce any unmeasurable results (p = 0.0055). In the remaining 41 estimations, a comparison of the measurements from the nasal septum versus the controls showed a mean difference of 0.15 and a limit of agreement of -0.106 to +0.398. A comparison difference of 2.27 and a limit of agreement of 1.986 to 2.551. CONCLUSION Monitoring SpO2 at the nasal septum site is more reliable than monitoring it at the finger site in hypothermic patients.

Adult respiratory distress syndrome after radical neck dissection

The clinical management of an unusual case of postoperative ARDS is reported. A few hours following neck surgery and septic insult, the patient developed unexpected ARDS. Aetiologic and supportive treatment were successfully instituted and after 72 hours of intensive therapy, the patient’s clinical status improved. The very short time lapse between the septic insult and appearance of ARDS is emphasized. A brief literature review on aetiology, diagnosis and therapy of sepsis, as well as some pertinent aspects concerning the pathogenesis of ARDS and its linkage to sepsis are presented.RésuméLa prise en charge clinique d’un cas inhabituel d’ARDS postopératoire est décrit. Quelques heures après une chirurgie du cou et une plaie septique, le patient a développé un ARDS imprévu. Une thérapeutique étiologique et curative fut mise en oeuvre et après 72 heures de soins intensifs, l’état du patient s’améliora. Il faut insister sur le délai très bref entre la plaie septique et l’apparition de l’ARDS. Une brève revue de la littérature sur l’étiologie, le diagnostic et le traitement du sepsis, ainsi que quelques points pertinents concernant la pathogénie de l’ARDS et ses rapports à un sepsis sont présentés.

Total intravenous anaesthesia for patients with osteogenesis imperfecta

Total intravenous anaesthesia for patients with osteogenesis imperfecta SiR-Osteogenesis imperfecta (011, an inherited autosomal dominant trait, has several anaesthetic implications. We recently encountered two children (10and 12years-old respectively) with 01 scheduled for reconstructive orthopaedic procedures under general anaesthesia. In both cases anaesthesia was induced with propofol (2.5 rngkg-’) and alfentanil (25 pg-kg-’) and after achieving an appropriate anaesthetic depth a laryngeal mask airway (LMA) was gently inserted with the head in neutral position. Anaesthesia was maintained with a continuous infusion of propofol (100-200 pgkg-’.min-’) and alfentanil (0.5-3.0 pg.kg-’.min-’), and supplemented with a mixture of 60:40% air and oxygen from a Siemens 900C ventilator in a CPAP mode. The patients were allowed to breath spontaneously while the Sp02, ETco2, temperature and the other vital signs were continuously monitored, and were within the normal limits. At the end of surgery, ten min after discontinuation of the propofol and alfentanil infusions, the patients were awakened smoothly. No perioperative complications were encountered. Patients with 01 have increased bone fragility and recurring fractures necessitating repeated surgical interventions. The main anaesthetic implications of 01 are: fragility of the cervical spine, mandible and teeth, kyphoscoliosis and abnormal platelet function. Other associated problems include aortic and mitral regurgitation, cleft palate and increased metabolic rate (Salem 1983). Tracheal intubation should be carried out with extreme caution due to the increased risk of damage to the teeth, mandible and cervical spine (Libman 1981). Because of the sporadic coincidental association between 01 and malignant hyperpyrexia (MH) (Rampton et al. 1984), drugs that may trigger MH should be avoided. Spinal and epidural anaesthesia may be hazardous due to the possibility of coincidental spina bifida and spine fractures. In the’ view of these risk factors, we conclude that continuous infusions of propofol and alfentanil while using the LMA, might be a safe approach to anaesthetic management of the patients suffering from 01. PETER SZMUK MD TIBERIU EZRI MD DAVID S~ROKER MD Department of Anaesthesia, Kaplan Hospital 76100 Rehovot, lsrael Correspondence to: P. Szmuk MD

Gas mask during pregnancy and labour

To the Editor: Propofol is useful not only as the sole agent for induction and maintenance of anaesthesia, but also as an adjunct during emergence after the use of a volatile anaesthetic. With the advent of procedures such as laparoscopy, it is often difficult to predict accurately when the procedure will end. Delivery of a volatile agent up to the end of the surgical procedure may delay emergence. In order to allow removal of the agent, its concentration is frequently reduced or eliminated in anticipation of completion of the case. Our timing is often misguided and the patient may require additional anaesthesia briefly during the final moments of surgery. Possible options include the use of: (1) an intravenous agent such as a barbiturate or propofol, (2) a narcotic, (3) a muscle relaxant, or (4) the volatile anaesthetic gas. I have found that the use of a subanaesthetic dose of propofol, i.e., 10--30 mg is sufficient to provide excellent anaesthesia at the final moments of surgery without delaying emergence. Due to its rapid distribution 13 and metabolism, the use of propofol is a more logical choice than (1) a barbiturate which may delay emergence and produce a less rapidly oriented patient, (2) a narcotic which may produce prolonged respiratory depression, nausea and/or vomiting, (3) a muscle relaxant which if given in close proximity to the end of the procedure may make reversal difficult, or (4) the addition of a volatile agent which may reanaesthetize the patient.

Cell-mediated immune suppression due to alfathesin in short-term anaesthesia

The immunosuppressive effects on cell-mediated immunity of alfathesin, when used as the sole agent for short-term anaesthesia, were investigated in ten women undergoingpregnancy termination. Cell-mediated immunity was evaluated by E rosette formation in peripheral blood (reflecting the percentage of T lymphocytes) and by proliferalive responses to the mitogens concanavalin A and phyto-haemagglulinin in various concentrations. Measurements were made before alfathesin was administered, and again after 60 minutes, two days and seven days. Significant reductions in the percentage of E rosettes in peripheral blood and in mitogenic responses to concanavalin A were observed 60 minutes after administration of alfathesin. A model is proposed in which alfathesin binds to lymphocytic membrane receptors, thus affecting in vitrocell-mediated immune reactions.RésuméL’effet immunosupressif de l’alfathesin, sur l’immunité par médiation céllulaire, quand celui-ci est employé comme agent unique de l’anesthésie de courte durrée, fait l’objet de cet étude. L’immunités par mediation cellulaire a été évaluée par la formation de rosettes E dans le sang périferique (ce qui reflète le pourcentage de lymphocytes T) et par la réponse proliférative aux mitogenes concanavaline A et phyto-aglutininne dans des concentralions variables. Les mesurements ont été fait avant l’administration de l’alfathesin, et puis après 60 minutes, deux et, réspectivement sept jours. Des réductions significatifes dans le pourcentage des rosettes E dans le sang périferique et dans la réponse mitogéne a la concanavaline A ont été observées 60 minutes après l’administration de l’alfathesin. Un modèle est proposé dans lequel l’alfathesin se lie aux récepteurs lymphocitaires de la membrane, et, de cette manière affecte les réactions immunitaires par mediation céllulaire in-vitro.