James W. Chapin

Fentanyl intermittent bolus technique for anesthesia in infants and children undergoing cardiac surgery

The use of fentanyl by an incremental intravenous (IV) bolus technique was evaluated in eight pediatric patients (ages 4 months to 5 years, ASA III-IV) undergoing corrective surgery for congenital heart defects. Anesthesia was induced with 5 to 10 micrograms/kg of fentanyl. Additional boluses of comparable size were given intermittently thereafter, in order that a total dose of 100 micrograms/kg was achieved just before instituting cardiopulmonary bypass (CPB). Heart rate, systolic blood pressure, various measures of anesthetic depth, and plasma fentanyl levels measured by radioimmunoassay were compared at various points during anesthesia, surgery, and recovery. Decreases in heart rate were observed at the time of sternal incision and at 30 minutes thereafter, when doses of fentanyl were near-maximal. No changes from baseline in systolic blood pressure or in anesthetic depth occurred at any of the intervals studied. The plasma concentration of fentanyl was 30 +/- 8 ng/mL just after completion of the fentanyl administration, immediately before CPB. With onset of CPB, the fentanyl level fell to 13 +/- 9 ng/mL, a statistically significant difference from the baseline value. No further change occurred over the additional 231 +/- 74 minutes in the operating room. The fentanyl concentration was 10 +/- 4 ng/mL upon entry into the recovery room. It is concluded that administration of fentanyl in small, intermittent IV boluses, with dosing completed before the onset of CPB, produces satisfactory plasma levels, anesthesia, and hemodynamic stability in children undergoing corrective surgery for congenital cardiac defects.

Hemorrhage and cardiac arrest during laparoscopic tubal ligation.

The article describes the case of a 38-year-old woman on whom laparoscopic tubal ligation was performed on an outpatient basis. During the procedure a 14 mm. tear was caused in the aorta, possibly by the Verres needle or the laparoscopic trocar, with subsequent hemorrhage and cardiac arrest. Similar cases are rarely reported in the literature. Still, it is important that facilities for massive transfusion should be available even in outpatient clinics.

Methylene blue and pulse oximeterreadings in a patient undergoing transurethral procedure

Abstract Herein we report on a patient with a decrease in the oxygen saturation reading by the pulse oximeter immediately following intravenous injection of methylene blue.

Anesthesia for glucagonoma resection

Anesthetic experience with three cases of the resection of glucagonoma, a rare tumor of alpha cells of pancreatic islets, is presented. Marked increases of blood glucagon and glucose levels, with the potential for clinically significant metabolic and myocardial dysfunction, did not occur during anesthesia and surgery. Associated tumors of other endocrine cell types also were absent in the three study patients. Strategies for anticipating and managing other perioperative problems associated with glucagonoma also are discussed.

The Effect of Intranasal Oxymetazoline on Serum Levels of Cocaine after Intranasal Cocaine Application

A prospective analysis was performed on healthy volunteers to determine whether pretreatment with the vasoconstrictor, oxymetazoline, could decrease the blood concentration of cocaine topically applied to the nasal mucosa. Blood pressure, pulse, continuous ECG recordings, and participant responses also were monitored as an indicator of systemic effects. Anesthesia was roughly assessed using a sterile 22-gauge needle touched to the anterior aspect of the inferior turbinate. Blood samples drawn at predetermined intervals were analyzed for cocaine using gas chromatography. Pretreatment with oxymetazoline significantly reduced the rate and extent of the increase in blood cocaine levels and resulted in a statistically significant lower systolic blood pressure and pulse rate. There was no significant difference in topical anesthesia between the two groups. Pretreatment with oxymetazoline before application of nasal cocaine thus appears to be beneficial.