Elif A. Akpek

Epidural anesthesia for renal transplantation : A preliminary report

PATIENTS receiving renal transplants present many problems to the anesthesists. Use of continuous epidural anesthesia in chronic renal failure patients is still controversial but promising. Since 1985 more than 900 transplantations have been carried out at our institution under general anesthesia. For the last 6 months we have routinely administered continuous epidural anesthesia for these procedures. In this study, we review recipient demographics, intraoperative anesthesia, postoperative analgesia strategies, and length of hospital stay and report on associated complications.

Intrathecal versus IV fentanyl in pediatric cardiac anesthesia.

Systemic large-dose opioids are widely used in pediatric cardiac anesthesia, but there are no randomized, prospective studies regarding the use of intrathecal (IT) opioids for these procedures. In this randomized, prospective study, we compared cardiovascular and neurohumoral responses during IT or IV fentanyl anesthesia for pediatric cardiac surgery. Thirty children aged 6 mo to 6 yr were anesthetized with an IV fentanyl bolus of 10 &mgr;g/kg. This was followed by a fentanyl infusion of 10 &mgr;g · kg−1 · h−1 (Group IV;n = 10), 2 &mgr;g/kg of IT fentanyl (Group IT;n = 10), or combined IV and IT protocols (Group IV + IT;n = 10). Heart rate, mean arterial blood pressure, additional fentanyl doses, time to first analgesic requirement, COMFORT and Children’s Hospital of Eastern Ontario Pain Scale scores, and extubation time were recorded. Blood cortisol, insulin, glucose, and lactate levels were measured presurgery, poststernotomy, during the rewarming phase of cardiopulmonary bypass (CPB), and 6 and 24 h after surgery. The patients’ urinary cortisol excretion rates were also measured during the first postoperative day. The findings in all three groups were statistically similar, except for higher blood glucose levels during CPB in Group IT compared with Group IV (P < 0.004). Group IV + IT was the only group in which the increases in heart rate and mean arterial blood pressure from presurgery to poststernotomy were not significant. The 24-h urinary cortisol excretion rates (&mgr;g · kg−1 · d−1) were 61.51 ± 39, 92.54 ± 67.55, and 40.15 ± 29.69 for Groups IV, IT, and IV + IT, respectively (P > 0.05). A single IT injection of fentanyl 2 &mgr;g/kg offers no advantage over systemic fentanyl (10 &mgr;g/kg bolus and 10 &mgr;g · kg−1 · h−1) with regard to hemodynamic stability or suppression of stress response. The combination of these two regimens may provide better hemodynamic stability during the pre-CPB period and may be associated with a decreased 24-h urinary cortisol excretion rate.

The effects of diltiazem and dopamine on early graft function in renal transplant recipients

ABSENCE OF, or poor, graft function in the early postoperative period following kidney transplantation remains a serious problem. To date, infusion of lowdose dopamine or administration of calcium channel blockers (CCB) has been used to reduce the incidence of acute tubular necrosis. The aim of this study was to investigate the effects of diltiazem and dopamine infusions on early graft function in renal transplant recipients, and to compare these effects with outcome in graft recipients who did not receive these agents.

Effects of anesthesia on linguistic skills: can anesthesia cause language switches?

References 1. Schulman SR: Rapacuronium redux. Anesth Analg 2002;94:483-4. 2. Rajchert DM, Pasquariello CA, Watcha ME, Schreiner MS. Rapacuronium and the risk of bronchospasm is pediatric patients. Anesth Analg 2002;94:488–93. 3. Sosis MB. On the Withdrawal of Rapacuronium by the FDA. Anesthesia Patient Safety Foundation Newsletter. 2001;16:30. 4. Berkowitz BA, Katzung BG. Basic and clinical evaluation of new drugs. In: Katzung BG, ed. Basic & Clinical Pharmacology, 7th ed. Stamford, CT: Appleton & Lange, 1998:62–72. 5. Wolfe SM. Do not use celecoxib (Celebrex) and rofecoxib (Vioxx) for arthritis—the misnamed and over priced “super aspirins.” Worst Pills—Best Pills 2001;7:27–9.

Peri- and postanalgesic properties of lidokain, lornoxicam, and nitroglycerine combination at intravenous regional anesthesia.

Background. This study was conducted to compare and evaluate the effect of adding lornoxicam or nitroglycerine as adjuncts to lidocaine in intravenous regional anesthesia (IVRA). Methods. 60 patients were randomly separated into three groups, lidocaine group (group L), lidocaine + lornoxicam group (group LL), and lidocaine + lornoxicam + transdermal nitroglycerine group (group LL-N). Hemodynamic parameters, sensory and motor blocks onset, and recovery times were recorded. Analgesic consumption for tourniquet pain and postoperative period were recorded. Results. Sensory block onset times and motor block onset times were shorter in the LL-N and LL groups compared with L group. Sensory block recovery time and motor block recovery time were prolonged in the LL and LL-N groups compared with group L. The amount of fentanyl required for tourniquet pain was less in group LL and group LL-N when compared with group L. VAS scores of tourniquet pain were higher in group L compared with the other study groups. Postoperative VAS scores were higher for the first 4 hours in group L compared with the other study groups. Conclusion. The adjuvant drugs (lornoxicam or TNG) when added to lidocaine in IVRA were effective in improving the overall quality of anesthesia, reducing tourniquet pain, increasing tourniquet tolerance, and improving the postoperative analgesia.

The Midterm Results of Cardiac Transplantation Patients

OBJECTIVE Cardiac transplantation is an important treatment option that increases the survival and decreases the limitations in effort capacity among patients with end-stage heart disease. In this study we have presented the midterm results of 13 patients who underwent cardiac transplantation between 2003 and 2007. PATIENTS AND METHODS There were 10 male and three female patients of mean age of 32 +/- 13.27 years (12 to 54). In one patient, we performed combined cardiac and renal transplantation. Ischemic cardiac disease was present in six patients and cardiomyopathy in seven patients. The mean age of the donors was 23.3 +/- 11.8 years (12 to 46). Corticosteroids, cyclosporine, and mycophenolate mofetil were used for immunosuppression. Sirolimus was employed in five cases due to impaired renal function. Patients were followed by echocardiography, endomyocardial biopsy, and dobutamine stress echocardiography. RESULTS The mean follow-up was 18.6 +/- 13.4 (1 to 38) months. In four patients, there was grade IIIA (II-R) rejection. In five patients, tacrolimus or cyclosporine was replaced with sirolimus due to elevated creatinine levels. Dobutamine stress echocardiography was positive in one patient, who displayed a severe left main coronary artery lesion. There was no operative mortality. There was only one hospital mortality (7.6%). Two patients died in the midterm. The overall mortality on follow-up was 3 (23.1%). The survival rates in the first, second, and third years were 92%, 88%, and 75%, respectively. Ejection fraction were more than 50%; all of posttransplant survivors showed good effort capacity. CONCLUSION Cardiac transplantation is a definitive, safe, and effective treatment for patients with end-stage heart failure.

Regional anesthesia in elderly patients undergoing carotid surgery: report of a case series.

Background: This study evaluates the short-term results in patients more than 75 years of age undergoing carotid endarterectomy at a single institution. Methods: Between June 2004 and June 2007, carotid endarterectomy operations were performed in 123 patients. A total of 70 patients had regional anesthesia. The data for all patients were retrospectively reviewed. Regional anesthesia and selective shunting was performed in all patients. Results: In 6 patients, a shunt was required. Primary closure of the carotid artery was performed in 22 patients and patch angioplasty was used in the remainder. There were no postoperative neurological complications. One patient died due to myocardial infarction. Conclusions: Carotid endarterectomy with regional anesthesia can be performed safely in the elderly population with low mortality and morbidity. Regional anesthesia may have advantages over general anesthesia and could potentially aid in avoiding complications related to shunt use.

Malposition of subclavian vein catheter due to undiagnosed persistant superior vena cava during pediatric cardiac surgery

nasopharynx. In case of oral route, the FOB is passed through an oral airway into the oropharynx (3). Then the pharynx, epiglottis, and glottis are in order visualized and anesthetized by spraying 3–4 ml of 2% lidocaine in aliquots of a 0.5–1.0 ml with an epidural catheter inserted through the suction channel. After adequate anesthesia of the vocal cords is obtained, the FOB is advanced into the upper trachea and 1–1.5 ml of lidocaine is sprayed. During the intubation, supplementary airway anesthesia is provided with single lidocaine injection through the FOB as required for patient comfort. 6. If airway anesthesia cannot be completed under awake condition because of children’s non-cooperation, general anesthesia with maintenance of spontaneous ventilation should be induced using inhalational or i.v. anesthetics. Then airway anesthesia is continued because it is important to minimize airway reflexes in pediatric patients undergoing fiberoptic intubation under general anesthesia with spontaneous ventilation. 7. According to our practice, the methods of airway anesthesia commonly used in adults may be used in children, with a few caveats. With a careful preparation, a well-considered plan and a satisfied procedure, airway anesthesia can be successfully completed in most of adolescents and mature preteens. Also providing topical anesthesia to the nasal and ⁄ or oral mucosa in combination with a method to anesthetize the pharyngeal, laryngeal, and tracheal structures is the most effective. But it must be emphasized that successful application of topical anesthetic to the airway is not a safe endpoint and the patient safety is always of paramount importance. One should keep firmly in mind the small size of pediatric patient and subsequent restriction on the volumes and amount of local anesthetics that can be used. The dosage of local anesthetic must strictly be kept within a safe limit. Fu Shan Xue Mao Ping Luo Ya Chao Xu Xu Liao Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China (email: fruitxue@yahoo.com.cn)

ABO-Incompatible Blood Transfusion and Invasive Therapeutic Approaches During Pediatric Cardiopulmonary Bypass

Human error has been identified as a major source of ABO-incompatible blood transfusion which most often results from blood being given to the wrong patient. We present a case of inadvertent administration of ABO-incompatible blood to a 6-mo-old child who underwent congenital heart surgery and discuss the use of invasive therapeutic approaches. Invasive techniques included total circulatory arrest and large-volume exchange transfusion, along with conventional ultrafiltration and plasmapheresis, which could all be performed rapidly and effectively. The combination of standard pharmacologic therapies and alternative invasive techniques after a massive ABO-incompatible blood transfusion led to a favorable outcome in our patient.

Brachial artery catheterization in congenital heart surgery

complications, which are largely agent-dependent, may include extremity gangrene and loss of limb (7). Additionally, although used as a temporizing measure to allow the administration of specific medications and fluid, some alternative form of vascular access must still be achieved. Therefore, we continue to believe that i.a. administration may be considered along with i.m. and i.o. routes when i.v. access cannot be achieved (8). Joseph Tobias Department of Anesthesiology & Pediatrics, University of Missouri, 3W-27G Health Sciences Center, One Hospital Drive, Columbia, MO, USA (email: tobiasj@health.missouri.edu)