Eli M. Brown

Intravenous regional anaesthesia (Bier block): review of 20 years' experience.

Our experience with intravenous regional anaesthesia (IVRA) in 1,906 patients over a period of 20 years has confirmed that this technique is safe and effective. IVRA may be used to provide anaesthesia for surgery involving both the upper and lower extremities. The need for supplemental medication is ordinarily minimal, so the technique is particularly suitable for short procedures in an ambulatory surgery centre. Yet, prolonged surgery may be performed using a “continuous technique.” Although various local anaesthetic agents may be used to induce IVRA no drug has been demonstrated to be superior to lidocaine. The major cause of failure of the technique or serious adverse effects is technical error. A specific protocol for avoiding technical error is presented. Significantly, over a period of 20 years, there has not been any mortality or major morbidity. The incidence of adverse reactions was 1.6 per cent and consisted of minor events such as transient dizziness, tinnitus or mild bradycardia.RésuméEn 20 ans, nous avons éprouvé l’efficacité et la sûreté de l’anesthésie intraveineuse régionale (IVRA) auprès de 1906 patients. Cette technique, applicable aux membres supérieurs et inférieurs, est particulièrement appropriée aux interventions de courte duree en externe et elle ne nécessite alors que tres peu d’adjuvants médicamenteux. Pour les chirurgies prolongies, il existe une technique iquivalente dite“continue”. line variété d’anesthésiques locaux a été utilisée, sans toutefois détrôner la lidocaïne. La plupart des echecs de l’IVRA de même que ses complications sérieuses sont imputables à une ou des erreurs techniques et nous vous présentons un protocole détaillé pour éviter de tels problèmes. Nous n’avons noté en 20 ans, aucun dices ni complications importantes autres que des étourdissements passagers, du tinnitus ou des bradycardies bénignes.

Physiologic alterations during pelvic laparoscopy.

Abstract We have reviewed our technique of anesthesia for laparoscopy and described our experience in a series of 90 patients. We had previously noted that when carbon dioxide is used to produce pneumoperitoneum during laparoscopy, there is a significant rise in arterial pCO 2 . When nitrous oxide is used for this purpose, we noted no significant alterations in arterial blood gases. It appears, therefore, that elevated arterial pCO 2 after insufflation of carbon dioxide into the abdomen is a result of absorption of the gas from the peritoneal cavity and not due to impaired ventilation during anesthesia. Although either gas may be used safely, nitrous oxide is probably somewhat superior for the reasons that we have outlined.

Anesthesia for pelvic laparoscopy.

To determine whether any problems are created with anesthetic management of patients undergoing pelvic laparoscopy blood gas levels and respiratory impedance measurements were taken on 24 consecutive pelvic laparoscopic patients. Anesthesia was induced with thiamylal sodium with entracheal intubation. Analysis of the changes in arterial blood gas and ventilation pressure and patient pulse pressure showed that the decrease in pH and increase in PaCO2 and ventilation pressure were significant (p less than .01) while the decrease in pulse pressure and PaO2 were not as highly significant (p less than .05). No major anesthetic difficulties were encountered.

Subdural Hematoma following Spinal Anesthesia

The purpose of this report is to describe a case of subdural hematoma following spinal anesthesia and to emphasize the importance of early diagnosis and appropriate treatment of this very serious condition

Outpatient laparoscopic sterilization under local anesthesia.

Abstract Arterial blood gases were monitored in a series of patients undergoing laparoscopy for tubal ligation under local anesthesia and sedation. The results revealed that there was a significant degree of hypoventilation and hypoxia due to the narcotic sedation; however, the procedure itself did not cause any further changes. Based on these findings and with the techniques as outlined, it is recommended that (1) supplementary oxygen be administered to the patient, (2) N 2 O be used to produce the pneumoperitoneum, and (3) the patient be encouraged to take occasional deep breaths during the procedure.

Pancuronium for rapid induction technique for tracheal intubation.

SummarySuxamethonium in a dose of 2 mg · kg-1 was compared to pancuronium in three different dosages (0.1 mg · kg-1, 0.15 mg · kg-1, 0.2 mg · kg1) for a rapid induction (crash) technique for tracheal intubation. Pancuronium 0.1 mg · kg-1 was inferior to suxamethonium, but the larger doses of pancuronium were equally satisfactory. In those instances where suxamethonium is either contraindicated or undesirable, pancuronium in a dose of 0.15 mg · kg-1 is a suitable alternative for rapid induction for tracheal intubation.RésuméNous avons comparé le pancuronium à la dose de 0.1, 0.15 et 2mg é kg-1, à la succinylcholine à la dose de 2 mg é kg-1, lorsque ces agents sont utilisés pour intubation rapide lors de ľinduction de ľanesthésie. Le pancuronium à la dose de 0.lmg é kg-1 s’est avéré inférieur à la succinylcholine, mais aux doses de 0.15 et de 0.2 mg é kg-1, il s’est avéré entièrement satisfaisant. Dans les cas où ľemploi de la succinylcholine est contre-indiqué ou indésirable, le pancuronium, à raison de 0.15 mg é kg-1 représente une alternative valable lorsqu’il est nécessaire de procéder à une intubation rapide.

Isoflurane anaesthesia for a patient with long Q-T syndrome

A case report of a patient known to have long Q-T syndrome (LQTS) undergoing elective oral surgery is presented. While nitrous oxide-narcotic, nitrous oxide-enflurane, or nitrous oxide-halothane techniques for anaesthetic management of LQTS have been previously reported, we report the use of nitrous oxide-isoflurane for the maintenance of anaesthesia. The authors feel that isoflurane is a safe anaesthetic agent for use in LQTS.RésuméOn rapporte l’observation d’un malade porteur du syndrome du Q-T prolongé qui a subi de la chirurgie stomatologiqite de façon élective. Les publications médicales font état de techniques d’anesthésie pour ces malades employant l’association morphinique-protoxyde d’azote protoxyde-enflurane ou protoxyde-halothane. Nous présentons ici un cas de technique employant une combinaison protoxyde d’azote et isoflurane. Nous avons l’impression que l’isoflurane est un agent qu’on peut employer avec sécurité chez des malades porteurs de ce syndrome.

Physostigmine reversal of scopolamine delirium in obstetric patients

The effects of intravenously administered physostigmine on the confusion and amnesia produced by scopolamine in the parturient patient were studied. In our patients, physostigmine completely reversed the central depression and amnesia produced by scopolamine. All patients became cooperative and oriented within 3 to 5 minutes and had good antegrade memory after administration of the drug. The effectiveness of physostigmine noted in this preliminary study warrants more definitive studies of the maternal and fetal elects of the drug. These studies are in progress.

Rapid sequence induction using vecuronium.

The purpose of this study was to determine the ideal priming and total dose of vecuronium when used as the relaxant during rapid sequence induction of anesthesia and tracheal intubation. Seventy patients were studied. Various priming and total dose schedules using vecuronium were compared with succinylcholine, 1.5 mg/kg. The mean onset times, intubating conditions, and mean duration times were compared. A priming dose of 10 μg/kg produced good intubation conditions with both 70 μg/kg and 150 μg/kg (total doses), but the mean onset times remained significantly longer than succinylcholine 1.5 mg/kg (P < 0.05). A priming dose of 15 μg/kg of vecuronium with 100 μg/kg total dose, on the other hand, not only produced excellent intubating conditions but also resulted in a mean onset time not significantly different from succinylcholine, 1.5 mg/kg. This latter dose schedule of vecuronium is recommended for rapid sequence induction when succinylcholine is contraindicated. Vecuronium is preferable to pancuronium for rapid sequence induction because of its lack of cardiovascular side effects and short duration.

Fentanyl/alfentanil for pelvic laparoscopy

Atfentanil, a new narcotic analgesic, was compared to fentanyl in a technique of balanced anaesthesia using thiopentone 5 mg·kg-1 for induction of anaesthesia, and pancuronium 60 µg·kg-1 to facilitate intubation. The study group consisted of 80 female patients scheduled for pelvic laparoscopy. The total dose of alfentanit averaged 2.06 mg (range 1.5-2.5 mg) whereas the dose of fentanyl averaged 0.21 mg (range 0.1-0.25 mg). There was no significant difference between the two groups in duration of anaesthesia, time to extubation, verbal response time or time to orientation to person, place and time. Following intubation, there was a significant rise in heart rate and blood pressure (p < 0.01) in both groups, but, again, there was no difference between groups. Post-operatively, the respiratory rate was not below 12 per minute for any patient in the study and was comparable for the two groups. The only significant side effect was postoperative nausea which occurred in over 40 per cent of patients and was not significantly different between the two groups.We conclude that alfentanil is a suitable narcotic drug for short surgical procedures on ambulatory patients, but the drug has no marked advantage over fentanyl for these procedures.RésuméAu cours d’ anesthésie balancée employant du thiopental 5mg·kg-1 pour l’induction de l’anesthésie et du pancuronium 60 µg·kg-1 pour effectuer l’intubation, nous avons comparé l’alfentanil, un nouvel analgésique morphinique au fentanyl. L’étude a été effectuée sur 80 sujets de sexe féminin subissant une laparoscopie pelvienne. La dose moyenne totale d’alfentanil était de 2.06 mg (1.5 à 2.5 mg) alors que la dose de fentanyl était de 0.21 mg (0.1 à 0.25 mg). On n’a observé aucune différence significative entre les deux groupes en termes de durée d’anestheésie, de temps écoulé jusqu’à l’extubation, jusqu’à la réponse aux ordres verbaux, jusqu’à l’orientation dans le temps et l’espace. A la suite de l’extubation, on a observé une augmentation significative de la fréquence cardiaque et de la pression artérielle (p < 0.01) dans les deux groupes mais ici encore on n’a pas observé de différence entre les groupes. En période post-opératoire, la fréquence respiratoire n’a jamais été en bas de 12 à la minute, fréquence qui est demeurée comparable dans les deux groupes. Le seul effet secondaire indesirable observé a été la nausée post-opératoire qu’on a détectée chez plus de 40 pour cent des malades dans l’un et l’autre groupe.Nous en concluons que l’alfentanil est un morphinique qui se prête à l’anesthésie pour opération de courte durée chez des malades ambulatoires mais ce nouveau médicament ne nous paraît pas présenter d’ avantages marqués sur le fentanyl.