Gaylord D. Alexander

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.

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.

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.

Procaine spinal anesthesia: a pilot study of the incidence of transient neurologic symptoms

STUDY OBJECTIVES To determine the approximate incidence of transient neurologic symptoms (TNS) [formerly known as transient radicular irritation (TRI)] associated with procaine spinal anesthesia, and whether fentanyl prolongs the duration of procaine spinal anesthesia. DESIGN Unrandomized pilot study. SETTING Community teaching hospital. PATIENTS 106 consecutive patients scheduled for spinal anesthesia for procedures anticipated to last less than 90 minutes. INTERVENTIONS All patients received 5% procaine for spinal anesthesia. Fentanyl 20 micrograms was added for procedures anticipated to last longer than 45 minutes (but less than 90 min). Intraoperatively the adequacy of duration, level, and intensity of anesthesia were observed. Time from injection of local anesthetic until knee-bending was recorded. Three days postoperatively, patients were questioned intensively in an effort to determine whether back pain and/or symptoms consistent with TNS had occurred. MEASUREMENTS AND MAIN RESULTS Duration of anesthesia was adequate in all but one instance. The intensity and the sensory level of anesthesia were satisfactory with one exception, a woman who had an unexpectedly low sensory level (L1) after 60 mg of procaine for cerclage, and who was also was the only patients to develop TNS. The incidence of TNS (0.9%) was markedly less than that reported after lidocaine and similar to the incidence observed after bupivacaine. Mild back pain without radiation occurred in 11 patients (10%), an incidence that is similar to that seen after bupivacaine and lidocaine. Compared with procaine alone, the addition of fentanyl significantly (p = 0.0001) prolonged the time to bending knees from 72 minutes to 97 minutes. CONCLUSIONS Procaine may be a useful alternative to lidocaine for short procedures, and it is less likely to produce TNS. Fentanyl prolongs motor block when added to procaine.

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.

A safe dose of vasopressin for paracervical infiltration.

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Maximal Inspiratory Volume and Postoperative Pulmonary Complications

The results of this study indicate that, in order to use any method of respiratory therapy intelligently and effectively in the postoperative period, it is imperative to know the preoperative maximal inspiratory volume of the patient and to measure the inspired volume during treatment. Only then can a physician determine if specific treatment is necessary at all, and if it is, whether or not incentive spirometry would be of greater benefit to the patient than intermittent positive pressure breathing therapy.