Leon Ovadia

Cervical epidural steroid injection for cervicobrachialgia

Fifty patients with chronic resistant cervicobrachialgia were randomly divided into two groups. Twenty‐five patients (group A) were treated with cervical epidural steroid/lidocaine injections and 17 patients (group B) were treated with steroid/lidocaine injections into the posterior neck muscles. Another eight patients from group B were excluded from the study because they had started the process of litigation of insurance claims and their subjective analysis of pain relief might therefore not be trustworthy. One to three injections were administered at 2‐week intervals according to the clinical response. All patients continued their various pre‐study treatments: non‐steroidal anti‐inflammatory drugs, non‐opioid analgesics and physiotherapy. Pain relief was evaluated by the visual analogue scale 1 week after the last injection and then 1 year later. One week after the last injection we rated pain relief as very good and good in 76% of the patients in group A, as compared to 35.5% of the patients in group B. One year after the treatment 68% of the group A patients still had very good and good pain relief, whereas only 11.8% of group B patients reported this degree of pain relief. These differences were statistically significant. We failed to achieve significant improvement of tendon reflexes or of sensory loss in both groups, but the increase in the range of motion, the fraction of patients who were able to decrease their daily dose of analgesics, and recovery of the capacity for work were significantly better in group A. We encountered no complications in either group of patients. We conclude that cervical epidural steroid/local anaesthetic injection is an effective method for achieving immediate and long‐standing pain relief and improvement in motion and performance in chronic resistant cervicobrachialgia.

The dilemma of immediate preoperative hypertension: to treat and operate, or to postpone surgery?

STUDY OBJECTIVE To evaluate the efficacy and complications of immediate preoperative reduction of arterial blood pressure (BP) in patients with well-controlled hypertension but with diastolic blood pressure (DBP) between 110 and 130 mmHg on arrival at the operating room (OR). DESIGN Prospective, randomized, large-sample study. SETTING University-affiliated, 550-bed community hospital. PATIENTS 989 patients with well-controlled hypertension, who were scheduled for surgery, and who had no previous myocardial infarction, unstable or severe angina pectoris, renal failure, pregnancy induced hypertension, left ventricular hypertrophy, previous coronary revascularization, aortic stenosis, preoperative dysrhythmias, conduction defects, or stroke. INTERVENTIONS Patients with DBP between 110 and 130 mmHg were randomly allocated to two groups: 400 patients in the control group and 589 patients serving as the study group. The control group had their surgery postponed and they remained in hospital for BP control, and the study patients received 10 mg of nifedipine intranasally delivered. The patients were observed for cardiovascular and neurological complications during the intraoperative period and over the first three postoperative days. MEASUREMENTS AND MAIN RESULTS The two groups were similar in age, gender, type of surgery, duration of anesthesia, and intraoperative fluid administration. There were no statistically significant differences in postoperative complications. The hospitalization time was considerable shorter in the study group than in the control group. CONCLUSIONS Immediate preoperative reduction of DBP with intranasal nifedipine is safe in patients with well-controlled arterial hypertension but they presented with severe to very severe hypertension for patients in the OR. We were able to avoid unnecessary surgery postponement and attendant costs.

Nasal ketamine for paediatric premedication

Ketamine in a dose of 6 mg · kg−1 was nasally administered in 86 healthy children (ASA I and II), aged from two to five years undergoing elective general, urological or plastic surgery, 20 to 40 min before the scheduled surgery time. These children were compared with 62 others, also aged from two to five years, in whom promethazine and meperidine, 1 mg · kg−1 of each, were injected im. Sedation was started as excellent in 48 and as adequate in 19 children in the ketamine group, compared with nine and 12 respectively in Group 2 (P < 0.05), while salivation was similar in both groups. We conclude that nasal ketamine is an alternative to im preanaesthetic sedation administration in children aged from two to five years.RésuméVingt à quarante minutes avant la chirurgie, de la kétamine 6 mg · kg−1 est administrée par voie nasale à 86 enfants en bonne santé (ASA I et II), âgés de deux à cinq ans programmés pour une intervention urologique ou plastique non urgente sous anesthésie générale. On compare ces enfants à 62 autres enfants du même âge, auxquels on a injecté par la voie i.m., soit de la mépéridine, soit de la prométhazine, à la dose de 1 mg · kg−1. La sédation est jugée excellente pour 48 et adéquate pour 19 des enfants du groupe kétamine, comparativement à 9 et 12 des enfants du groupe 2 (P < 0,05), alors que la salivation est identique dans les deux groupes. Nous en concluons que la kétamine nasale est une alternative a la prémédication intramusculaire pour des enfants de deux à cinq ans.

Lidocaine pretreatment effectively decreases the incidence of hiccups during methohexitone administration for dilatation and curettage

The efficacy of lidocaine 1 mg · kg‐1 for prevention of methohexitone‐induced hiccups was assessed in a double‐blind fashion in 200 patients undergoing dilatation and curettage for pregnancy interruption. The patients were randomly assigned to receive either lidocaine 1% or saline 0.9% in a similar way (1 ml for every 10 kg of body weight). The incidence of hiccups was 16% in the control group compared to 6% in the lidocaine group. We speculate that this reduction in the methohexitone‐induced hiccup ratio is related to lidocaines membrane‐stabilizing properties, which decrease the excitability of all the nervous structures involved in this reflex.

Retrograde tracheal intubation: beyond fibreoptic endotracheal intubation.

Background:  Flexible fibreoptic laryngoscopy is the method of choice for coping with difficult tracheal intubations, a leading cause of catastrophic outcomes in anaesthesia. However, this technique is not always available or feasible. Retrograde intubation is a minimally invasive airway management technique with a flat learning curve and a high level of skill retention.

Is penile block better than caudal epidural block for postcircumcision analgesia

PurposeTo compare caudal and penile block for post-operative analgesia in children undergoing circumcision with respect to efficacy, complication rates, and parental satisfaction.MethodsThe study population consisted of 100 ASA 1 and 2 boys aged 3 to 8 years who were undergoing circumcision for religious reasons. In all participants, inhalation anesthesia was administered with oxygen : nitrous oxide (1 : 2) and halothane. The participants were allocated randomly into two groups of 50 children each. Group 1 received penile block and Group 2 caudal block. The penile block was achieved by injecting bupivacaine into the two compartments of the subpubic space, with an additional ventral infiltration of a small volume of bupivacaine along the raphe of the penis. For caudal block, 1 ml·kg−1 body weight of 0.25% bupivacaine was administered.ResultsPenile block shortened the induction-incision time and enabled earlier discharge home compared with caudal block. One patient undergoing penile block and nine patients undergoing caudal block vomited.ConclusionsPenile and caudal block are equally effective for postcircumcision analgesia and neither is associated with serious complications. Anesthesiologist preference should be the deciding factor in choosing one technique over the other.

Continuous arteriovenous hemofiltration in the treatment of amniotic fluid embolism

Continuous arteriovenous hemofiltration (CAVH) was successfully used in a 35-year-old woman, who had developed amniotic fluid embolism in the course of a premature labor and cesarean delivery. With CAVH, the pulmonary artery pressure decreased, the cardiac index rose, and the arterial oxygenation improved dramatically. This technique seems to be an important contribution to the management of amniotic fluid embolism.

Nasal continuous positive airway pressure: an alternative method for respiratory assistance.

STUDY OBJECTIVE To examine the efficacy of a nasal continuous positive airway pressure (CPAP) system for respiratory support in patients who have respiratory insufficiency but are able to maintain spontaneous breathing without hypercapnia, respiratory acidosis, or deteriorated mental status. DESIGN Prospective study. SETTING Medical and surgical patients admitted to the intensive care unit (ICU) at the Hillel Yaffe Medical Center. PATIENTS Nineteen patients with acute respiratory insufficiency and intact mental status who were able to maintain spontaneous breathing without hypercapnia or respiratory acidosis. Additional entry criteria were as follows: arterial oxygen tension (PaO2) less than 65 mmHg on inspired oxygen tension (FIO2) greater than or equal to 0.45, PaO2/FIO2 less than 150, respiratory rate greater than 35 breaths/minute, and inability to tolerate mask CPAP. INTERVENTIONS Nasal CPAP (10 cmH2O) was applied to patients through two nasopharyngeal airways with an internal diameter (ID) of 8 mm each, inserted in both nostrils. During CPAP application, the patients were requested to breathe through their nose with their mouth closed. Even if they breathed through their open mouth, however, CPAP was maintained despite an observed pressure decrease of 4 cmH2O. MEASUREMENTS AND MAIN RESULTS All patients showed a constant improvement in arterial blood gases, PaO2/FIO2, and respiratory signs during nasal CPAP of 10 cmH2O. PaO2 increased from 52 +/- 5.3 mmHg to 131 +/- 20 mmHg with CPAP administration (p less than 0.05), while arterial carbon dioxide tension (PaCO2) increased from 32 +/- 2 mmHg to 36 +/- 2 mmHg (p less than 0.05) and respiratory rate decreased from 39 +/- 2.3 breaths/minute to 31 +/- 1.6 breaths/minute (p less than 0.05). CONCLUSIONS Nasal CPAP (10 cmH2O) is a reliable alternative to support arterial oxygenation in patients with respiratory failure who are alert and vigorous enough to avoid hypercapnia and respiratory acidosis while breathing spontaneously. In addition, since the patients are able to speak and thus are capable of expressing their feelings, the anxiety observed during respiratory support can be reduced.

Comparison of visceral pain incidence during cesarean section performed under spinal or epidural anesthesia

The incidence of visceral pain during cesarean section performed under regional anesthesia was studied in 80 unpremedicated patients. They were divided in two similar groups concerning age, weight and height. Group 1 consisted of 40 patients submitted to cesarean section under spinal anesthesia, while in group 2 (40 patients) epidural anesthesia was used. Surgery was totally painless for all patients of group 1 patients, whereas in group 2 intraoperative analgesia was complete for 11, good in 18 and fair in 10 patients. One patient of group 2 required general anesthesia due to excrutiating pain during exteriorization of uterus despite a seemly adequate lebel of cutaneous analgesia of T 6 · The authors conclude that spinal anesthesia favorably compares with epidural anesthesia for cesarean section, because the incidence of visceral pain with the former was nill and because both techniques are equally safe for mothers and neonates

Sore throat incidence with the laryngeal mask: A comparison with orotracheal intubation

The incidence of sore throat was evaluated among 80 healthy (ASA 1 and 2) nonpremedicated adult patients undergoing general anesthesia for general, plastic, urologic, gynecologic, and orthopedic surgery. The patients were randomly allocated in two groups: group one (n=39) consisted of patients in whom the airway was maintained by a laryngeal mask, and in group 2 (n=40), orotracheal intubation was performed. Both groups were similar in age, gender, site of surgery, and time of airway cannulation. Intraperitoneal surgery of the upper abdomen, and insertion of a nasogastric tube were exclusion criteria. The severity of sore throat was graded by the patients themselves using a visual analogue 100 mm scale, varying from 0 (no sore throat) to 10 (extremely sore). The sore throat incidence, severity and duration were significantly lower in the laryngeal mask group in comparison with the endotracheal intubation group.