Robert E. Middaugh

The successful treatment of dural puncture headache after failed epidural blood patch.

Puncture of the lumbar dura can lead to a severe and often incapacitating headache. A single injection of autologous blood into the epidural space relieves the headache in 90% of the patients so affected, whereas a second blood patch successfully treats the majority of those in whom the first blood patch is ineffective (1 ) . The management of patients in whom the repeat blood patch fails is not clear. We describe the effective treatment of postdural puncture headache in two patients using patient-controlled, continuous, epidural infusion of saline after failed epidural blood patch.

Rapid-sequence orotracheal intubation: A comparison of three techniques

The authors compared tracheal intubating conditions using three techniques for rapid-sequence orotracheal intubation. Sixty patients were randomly assigned to one of three groups: priming with vecuronium (0.01 mg/kg priming dose, 4-min priming interval, 0.14-mg/kg intubating dose along with thiopental 4-6 mg iv); timing with vecuronium (0.15-mg/kg intubating dose given before thiopental and timed to weakness of hand grip); and succinylcholine (1.5 mg/kg). Blinded intubators graded intubating conditions 60 s after the induction of anesthesia with thiopental. Intubation scores in the succinylcholine group were significantly better than in the priming group (P = 0.009). Intubation scores of the succinylcholine and the timing groups were not significantly different. Use of the timing principle for rapid-sequence orotracheal intubation is a reliable alternative in cases where succinylcholine is contraindicated.

Reflex Sympathetic Dystrophy: A Complication of Interscalene Block

Interscalene block of the brachial plexus is a reliable means for providing anesthesia of the shoulder and upper extremity. As with all anesthetic techniques, there are potential complications. The following case illustrates the occurrence of reflex sympathetic dystrophy (RSD) after an interscalene block with 3% 2chloroprocaine. To the best of our knowledge, there is no previous case in the literature of RSD associated with interscalene block.

Rapid tracheal intubation with vecuronium: The timing principle

A method of administration of vecuronium for intubation that allows excellent intubating conditions in 60 seconds after the induction of anesthesia is described. Patients were divided into three groups based on the dose of vecuronium given. These patients were given either 0.10 mg/kg, 0.15 mg/kg, or 0.20 mg/kg of vecuronium intravenously. Intubating doses of vecuronium were given prior to the induction of anesthesia with sodium thiopental. Administration of the sodium thiopental was timed to the onset of clinical weakness in each patient.

Comparison of bretylium and lidocaine in the prevention of ventricular fibrillation after aortic cross-clamp release in coronary artery bypass surgery☆

The authors compared bretylium and lidocaine for reducing the incidence and persistence of ventricular fibrillation following aortic cross-clamp release performed during coronary artery bypass surgery. Thirty-three adult patients scheduled for elective bypass surgery were randomly assigned in a double-blind fashion to receive a bolus of bretylium, 10 mg/kg, lidocaine, 2 mg/kg, or saline, in equal volumes prior to the release of the aortic cross-clamp. Coronary artery bypass surgery was conducted using standard cardiopulmonary bypass (CPB) procedures with systemic cooling to 24 degrees to 28 degrees C. Temperature, arterial blood gases, and electrolytes were recorded. After clamp release, the first electrical rhythm was noted. Abnormal rhythms (ventricular fibrillation) were allowed to persist for 1 to 2 minutes, and if spontaneous conversion to a supraventricular rhythm did not occur, defibrillation with internal DC countershocks was applied. Patients were compared with respect to occurrence of ventricular fibrillation, need for DC countershocks, antiarrhythmic drugs, and inotropic support. There was no significant difference among the groups with respect to age, sex, preoperative medications, past medical histories, ejection fractions, average number of bypasses, cross-clamp times, or temperatures during bypass. The incidence of ventricular fibrillation after aortic cross-clamp removal was: saline 91%, lidocaine 64% (P less than 0.01), and bretylium 36% (P less than 0.01). The number of countershocks required to defibrillate, while lower in the bretylium group, did not reach statistical significance. After cardiopulmonary bypass, cardiac output and systemic vascular resistance were comparable. Bretylium warrants further study in this setting.