Paul J. Poppers

A comparison of cocaine, lidocaine with epinephrine, and oxymetazoline for prevention of epistaxis on nasotracheal intubation

The alpha-adrenergic agonist oxymetazoline was compared to cocaine and to lidocaine with epinephrine with respect to prevention of epistaxis on nasotracheal intubation. The nares of three groups of 14 patients each were topically pretreated with 4% lidocaine with 1:100,000 epinephrine (group 1), 10% cocaine (group 2), or 0.05% oxymetazoline (group 3) prior to nasotracheal intubation. After intubation, epistaxis was estimated on a scale of 0 to 3, with 0 indicating no bleeding, 1 representing blood on the nasotracheal tube only, 2 indicating blood pooling in the pharynx, and 3 representing blood in the pharynx sufficient to impede intubation. Only 29% of the patients in group 1 displayed no bleeding, whereas 57% of those in group 2 and 86% of those in group 3 had no bleeding. Nonparametric analysis showed a statistically significant difference (p less than 0.013) between oxymetazoline and lidocaine with epinephrine. In addition, heart rate (HR) and blood pressure (BP) were examined prior to administration of the medications; at 5 minutes, 10 minutes, and 15 minutes after administration of the medications; and after intubation. No significant differences were noted (p greater than 0.05) between the medications except for a slightly higher systolic BP for cocaine than for lidocaine with epinephrine at 15 minutes. The results of this double-blind, randomized trial demonstrate that the alpha-adrenergic agonist oxymetazoline is as effective as cocaine, and more effective than lidocaine with epinephrine, for the prevention of epistaxis associated with nasotracheal intubation.

Use of EMLA cream in the treatment of post-herpetic neuralgia

EMLA cream is an acronym for eutectic mixture of local anesthetics. It contains lidocaine and prilocaine creams. A eutectic preparation, applied topically, penetrates into the dermis after an application period of 1 to 2 hours. This case report describes the successful treatment with EMLA cream of post-herpetic neuralgia, which was resistant to other modes of therapy, and briefly discusses the pharmacology of EMLA cream.

False aneurysm of the axillary artery following brachial plexus block

Brachial plexus blockade is a commonly used technique for providing surgical anesthesia for the upper extremity. Although various approaches have been described, the axillary approach is the safest and most frequently used. Most complications associated with axillary nerve block are related to local or systemic anesthetic toxicity, bleeding, infection, and nerve damage. A case of false aneurysm of the axillary artery following axillary nerve block is reported. The possible occurrence of this complication should be kept in mind to avoid permanent neurologic sequelae.

Prolonged Neuromuscular Blockade Following Vecuronium Infusion

Administration of vecuronium by infusion is an increasingly common technique, both in the operating room and in the intensive care unit (ICU), for patients requiring prolonged neuromuscular blockade and mechanical ventilation. The major advantage of vecuronium over older neuromuscular blocking agents is its rapid excretion and intermediate duration of action. Prior to the current case report, the longest reported continuous paralysis after the cessation of a vecuronium infusion was 90 hours. A case of an 81-year-old patient with renal failure and subclinical chronic cirrhosis of the liver, who remained paralyzed for 13 days following a vecuronium infusion, is described. Intensive monitoring of neuromuscular function is recommended whenever muscle relaxants are administered by continuous infusion.

Bronchodilating effects of the anesthetic ketamine in an in vitro guinea pig preparation

Ketamine, a dissociative anesthetic, is capable of reducing airway resistance and has proved useful in anesthetizing surgical patients with acute or chronic bronchospasm. To determine if ketamine alters smooth muscle tone, the relative responses of large and small airways of the same animal were studied by comparing the pharmacologic reactivity of tracheal smooth muscle strips with that of a specially prepared perfused bronchial tree. Trachealis and bronchial smooth muscle were found to react to methacholine and histamine in a concentration-dependent manner and have similar sensitivities. Ketamine, by itself, in the concentration range 10−8–10−3 M did not alter resting tone as compared to epinephrine, which reduced baseline tone. In tissues precontracted with histamine or methacholine at ED50 doses, ketamine inhibited smooth muscle contraction. In a second series of experiments, the dose-dependent contraction of smooth muscle to histamine and methacholine was reevaluated in the presence of ketamine. Both tissue sensitivity and maximum contractile response to these agonists were reduced by ketamine at 10−4 M. These data indicate that ketamine alters the in vitro response of guinea pig airways to agonists associated with the asthmatic state. Although ketamine does not reduce airway tone in nonstimulated tissues, its effects on agonist-induced contraction of airway tissues in vitro are consistent with clinical observations that ketamine relieves bronchospasm.

Intraoperative management of a patient with a chronic, previously undiagnosed traumatic diaphragmatic hernia

Traumatic diaphragmatic hernia (TDH) occurs in approximately 5% of hospitalized motor vehicle accident victims and 10% of victims of penetrating chest injury. Although most such injuries are diagnosed at the time of initial trauma, approximately 10% become apparent only months or years later. The TDH patient is at risk for surgical complications, including pulmonary aspiration, hypoxemia, and hemodynamic instability. Diagnosis and proper management of TDH is essential in order to minimize such complications. The anesthetic management of a patient with a preexisting TDH presenting for lumbar laminectomy is discussed.

Automated anesthesia surgery medical record system

Manual recording of physiological data in patients receiving anesthesia or intensive care infrequently meets medical requirements or legal documentation standards. Automated recording allows the generation of reliable data that can be integrated into the patients medical record. Such a system is beginning to function at University Hospital at Stony Brook, New York. Bedside medical devices (pulse oximeters, non-invasive blood pressure monitors, capnographs, infusion pumps and physiological monitors) from 18 operating rooms and 16 beds in the Anesthesia Intensive Care Unit are connected to a baseband Ethernet system. Data from the above devices are stored in a MicroVAX computer system. Data compression and interpretation, computation of derived values, statistical analysis of data from two related parameters are done by the bedside graphical microcomputer workstation. The Micro VAX computer and the workstation are also connected to the Ethernet system. The overall architecture of the automatic record system conforms to emerging standards for information exchange between bedside monitors and computer systems. Health care recipients and providers are likely to reap the benefits.

Complex regional pain syndrome (CRPS) with resistance to local anesthetic block: a case report

We present a case of complex regional pain syndrome (CRPS) Type 1 in a 12-year-old girl. The patient did not respond to the usual therapeutic modalities used to treat CRPS, including physical therapy, lumbar sympathetic block, epidural local anesthetic block, intravenous lidocaine infusion, or other oral medications. Of note is the fact that, during epidural block, the patient demonstrated a resistance to local anesthetic neural blockade in the area of the body involved with the pain problem. The mechanism of this resistance could be related to the changes in the dorsal horn cells of the spinal cord, secondary to activation of N-methyl-D-aspartate receptors, which may play a role in the pathophysiology of this pain syndrome.

An Evolutionary Solution to Anesthesia Automated Record Keeping

In the course of five years the development of an automated anesthesia record keeper has evolved through nearly a dozen stages, each marked by new features and sophistication. Commodity PC hardware and software minimized development costs. Object oriented analysis, programming and design supported the process of change. In addition, we developed an evolutionary strategy that optimized motivation, risk management, and maximized return on investment. Besides providing record keeping services, the system supports educational and research activities and through a flexible plotting paradigm, supports each anesthesiologists focus on physiological data during and after anesthesia.

Application of the Grieshaber® air system to maintain endotracheal tube cuff pressure

The Grieshaber Air System was designed to maintain intraocular pressure during ophthalmologic surgery. It also has been used to maintain pressure in leaking endotracheal tube cuffs. It is a very useful device, especially if the intubation is difficult or the patients position precludes replacement of the endotracheal tube. Two patients are presented in whom the system was used to maintain endotracheal tube cuff pressure.