Specialty
Spotlight

 




 


Anaesthesia


   

 



  • Tait
    AR, Pandit UA, Voepel-Lewis T, et al


    Use
    of Laryngeal Mask Airway in Children with Upper
    Respiratory Tract Infections: A Comparison with
    Endotracheal Intubation


    Anesth Analg 86:706-711, 1998


       

    There
    is debate over whether to proceed with anesthesia in
    children with upper respiratory infections [URI] who
    are sent for elective surgery. 
    Endotracheal tube placement [ETT] may
    increase the risk of complications in children with
    URI.  The
    laryngeal mask airway [ LMA ] provides a new
    approach to airway management. 
    This study compares the LMA with ETT in
    children with URI.

     

    The
    randomized trial included 82 children, aged 3 months
    to 16 years, undergoing elective surgery with URI. 
    Those with lower respiratory tract infection
    were excluded. 
    Half of the patients were managed with LMA
    and half with ETT, both placed under standard
    techniques.  Both
    groups underwent induction of anesthesia with
    nitrous oxide, oxygen, and halothane. 
    Patients were monitored from induction
    through postanesthesia for complications such as
    cough, laryngospasm, bronchospasm, breath-holding,
    and arrhythmias. 
    Arterial oxygen desaturation [pulse oxymetry
    of less than 90%] was considered a major
    desaturation event.

       

    The
    LMA and ETT groups were comparable in terms of age,
    anesthesia and surgery times, number of tube
    placement attempts, and URI symptoms. The two methods produced similar incidence of
    cough, breath-holding, excessive secretions and
    arrythmias. There
    was also no difference in the incidence of
    laryngospasm, although one patient with an ETT
    required muscle relaxant for this complication. Mild
    bronchospasm occurred in 12% in the ETT group and
    none in the LMA group. 
    Major desaturation events were also more
    common with ETT, 12.5% vs 0%. Respiratory complications were also more in
    the ETT group, 35 vs 19 in the LMA group. Still, the respiratory complications were
    easily managed in all with no adverse sequelae. Thus overall LMA offers a better choice than
    ETT in the anesthetic management of children with
    URI.

        

  • Hogan
    G



    Epidural Catheter Tip Position and Distribution of
    Injectate Evaluated by Computed Tomography



    Anesthesiology
    90: 964-970, 1999


      

    Asymmetric
    epidural blockade is common, occurring in as many as
    21% of patients. Patterns of asymmetric distribution
    have not been studied. 
    Catheter positions and patterns of
    circumferential distribution of solution injected
    during routine epidural anesthesia were assessed by
    means of CT.

     

    20
    women, average age 55 years, undergoing
    brachytherapy for cervical cancer, under epidural
    anesthesia were studied.
    A continuous infusion of bupivacaine and
    fentanyl was provided and adjusted throughout the
    course of brachytherapy.
    The level of analgesia was determined by pin
    scratch, and ability to flex ankles, knees, and hips
    was documented twice daily. 
    Four hours after surgery, CT was performed to
    guide placement of radiation sources.
    The tip of the epidural catheter was
    identified, contrast material injected, and a series
    of images was obtained.
    The images were examined by evaluators who
    were blinded to the extent of analgesia.

       

    Results
    showed the catheter was placed at the desired level
    in 8 patients, higher than intended in 11 and
    through the posterior epidural fat in 1 patient. 
    Eight catheter tips were in or near the
    posterior epidural space, 9 in the intervertebral
    foramina and two in the paravertebral tissues
    lateral to the intervertebral foramina.
    Patterns of spread were not consistent,
    although most showed spread anterior to the dura,
    and most showed posterior and lateral spread.
    In most patients, the contrast material left
    asymmetrically through the intervertebral foramina
    into the psoas muscles.
    Air bubbles and fat arrested distribution of
    analgesia in two patients.  Layering of the solution without foraminal spread was seen in
    9 of 15 patients after a 4 mL injection, and in 5 of
    19 patients after a 10 mL injection.
    Subdural accumulation was noted in one
    patient, and leakage through
    the ligamentum flavum in two. 
    Most patients had block levels that differed
    by 2 or fewer segments, 2 patients had maximum
    difference of segments and one had a difference of 4
    segments. Thus catheter position and analgesia distribution vary greatly from
    patient to patient but adequate analgesia is
    provided in most cases.

       

  • Ziser
    A, Plevak DJ, Wiesner RH, et al




    Morbidity
    and Mortality in Cirrhotic Patients undergoing
    Anesthesia and Surgery


    Anesthesiology
    90: 42-53, 1999


     

    Patients
    with cirrhosis of liver who undergo anesthesia and
    surgery have an increased mortality rate.
    Factors that might predict perioperative
    complications and death in such patients were
    retrospectively investigated.

     

    Records
    of 733 patients [338 women], aged 18 to 87 years,
    undergoing surgery, over a 11 year period, were
    reviewed for demographic information and concurrent
    medical conditions. Patients were followed up 2.7 to
    13.7 years. A
    questionnaire was mailed to living patients, asking
    about their health and whether or not they had had a
    liver transplant; those who had a liver transplant
    were excluded from the study.

      

    Results
    showed, postoperative complications, most commonly
    pneumonia, occurred in 222 patients [30.1%].
    There were 72 in hospital deaths [9.8%], and
    13 out-of-hospital deaths [1.8%], within 30 days of
    surgery.  Most
    of the deaths occurred in the immediate
    post-operative period; 8 variables were associated
    with death and included male sex, a high Child-Pugh
    score, ascites, cryptogenic cirrhosis, elevated
    creatinine level, preoperative infection, a high ASA
    status, and respiratory surgery.

       

  • White
    CM, Dunn A, Tsikouris J, et al [Hartford Hospital,
    Conn., Univ of Connecticut, Storrs]


    An
    Assessment of the Safety of Short-Term Amiodarone
    Therapy in Cardiac Surgical Patients with Fentanyl
    Isoflurane Anesthesia


    Anesth
    Analg 89: 585-589, 1999

     

    Chronic
    amiodarone use, in combination with fentanyl
    anesthesias, may cause atrioventricular blockade,
    symptomatic bradycardia, sinus arrest, and severe
    hypotension. The
    effect of short-term amiodarone use has not been
    investigated. The
    effect on hemodynamics of fentanyl-containing
    anesthesia, administered to elderly patients
    receiving short-term amiodarone therapy before
    coronary artery bypass graft [CABG] or vascular
    surgery, was investigated in a prospective,
    randomized, double-blind, placebo-controlled trial.

     

    Elderly
    CABG patients were randomly allocated to receive
    amiodarone 3.4 g over 5 days, or 2.2 g over 24 hours
    [n=45] or placebo [n=39], before CABG. Fluid balance, use of dopamine, use of vaso-pressor catecholamines,
    and use of phospho- diasterase inhibitor or
    intra-aortic balloon pump were recorded.  Systolic,
    diastolic and central venous pressures were
    measured, before anesthesia, before cardiopulmonary
    bypass [CPB] and after CPB.
    Heart rates were recorded before induction of
    anesthesia and after CPB.

     

    Results
    showed fluid status increase by 2L in 2 [4.4%]
    amiodarone patients and in 4 [10.3%] placebo
    patients. No
    patient required dopamine or an intra-aortic baloon
    pump. Epinephrine or derivative was administered to
    8 [17.8%] amiodarone and 5 [12.8%] placebo patients
    and milrinone to 1 [2.2%] amiodarone and 2 [5.1%]
    placebo patients. Preanesthesia and post PCB
    systolic blood pressure, were significantly lower in
    amiodarone patients. 
    Further, amiodarone patients received less
    fluid and had a lower net increase in fluid status,
    than the placebo patients, although the differences
    were not significant.

      

    Thus
    short term amiodarone therapy does not lead to
    hemodynamic instability in CABG patients receiving
    fentanyl anesthesia regimens.

       

  • Webster
    AC, Morley-Forster PK, Janzen V, et al [ Univ of
    Western Ontario, London]


    Anesthesia
    for Intranasal Surgery : A Comparison Between
    Tracheal Intubation and the Flexible Reinforced
    Laryngeal Mask Airway


    Anesth
    Analg 88: 421-425, 1999

     

    Prototype
    flexible reinforced laryngeal mask airways [LMAs],
    do not directly stimulate the larynx and therefore
    reduce the respiratory and cardiovascular reflex
    responses to placement and removal.
    A study was undertaken to determine whether
    the use of flexible reinforced LMA for anesthesia in
    intranasal surgery can reduce the incidence of
    airway complications without compromising airway
    protection as compared with tracheal intubation.

     

    Outpatients
    undergoing endoscopic intranasal surgery or
    septoplasty were randomly allocated to size 4
    flexible reinforced LMA with spontaneous breathing
    and removal while awake [group 1, n=35], tracheal
    intubation with cuffed endotracheal tube with
    intermittent positive pressure ventilation and
    extubation while awake [ group 2, n=34], and
    tracheal intubation with spontaneous breathing and
    extubation while deeply anesthetized [group 3,
    n=32]. Incidence of coughing, sore throat,
    hoarseness, blood loss, and oxyhemoglobin
    desaturation at removal were recorded.

     

    The
    incidence of laryngospasm was 0 in group 1, 6% in
    group 2, and 19% in group 3. The incidence of
    oxyhemoglobin desaturation was 0 in group 1, 26% in
    group 2, and 16% in group 3.
    The time between discontinuation of
    anesthesia and departure from the operation room was
    significantly less in group 1 than in group 2 
    and group 3 [10.74 vs 14.85 vs 12.16 min].
    Whereas all groups had a high incidence of sore
    throat on the first postoperative day, the incidence
    of hoarseness was significantly lower in group 1
    than in groups 2 and 3.

     

    Thus
    flexible, reinforced LMA is safe and more effective
    than endotracheal intubation for use during
    intranasal surgery.

       

  • Lowinger
    D, Benjamin B, Gadd L. [St Luke’s 
    Hospital, Sydney, Australia]


    Recurrent
    Laryngeal Nerve Injury Caused by a Laryngeal Mask
    Airway

    Anaesth Intensive Care 27: 202-205, 1999

     

    There
    are reports of laryngeal nerve damage after the use
    of laryngeal mask airways [LMA]. A rare case of
    permanent unilateral vocal cord paralysis that
    required thyroplasty for voice restoration is
    reported.

     

    Male,
    44, employed as announcer, underwent ligation of
    varicose veins. After anesthesia was induced, a size 4 LMA was inserted.
    The cuff was inflated to 20 mL of air but the
    cuff pressure was not monitored. 
    After uneventful surgery, the LMA was
    removed. Over the next 24 hours patient experienced dysphonia without pain,
    which went on to aphonia by day 2. The left vocal
    cord was seen to be immobile with no other
    neurological abnormality. At 6 months left cord paralysis was confirmed without arytenoid
    cartilage dislocation or other glottic disorder. A
    trial injection of Gelfoam at 9 months restored good
    voice for a few weeks. At 12 months, thryroplasty was performed with a 4 mm hydoxyapatite
    prosthesis, and the patient’s voice improved though
    the cord paralysis persisted.

     

    Whereas
    LMA is generally safe and effective, in rare cases
    it can lead to persistent dysphonia, probably as a
    result of extensive ischemia with demyelination and
    neural loss.

      

  • Hurlbert
    RJ, Theodore N, Drabier JB, et al [Univ of Calgary,
    Alta; St Joseph’s Hosp, Phoenix, Ariz]


    A Prospective Randomized Double- Blind
    Controlled Trial to Evaluate the Efficacy of an
    Analgesic Epidural Paste Following Lumbar
    Decompressive Surgery


    J
    Neurosurg : Spine 90: 191-197, 1999

     

    Pain
    management after lumbar surgery currently relies on
    systemic narcotics, which carry significant side
    effects and can delay, return to activities.

     

    An analgesic paste containing morphine and
    methylprednisolone was evaluated for its ability to
    control postoperative pain after lumbar spine
    decompression.

     

    Applied directly to the dura just before wound
    closure, an analgesic epidural paste can
    significantly improve pain control after lumbar
    spine decompressive surgery.

     

    Analgesic paste is a safe and effective treatment
    that may become a new standard of care for patients
    undergoing lumbar decompression and other surgical
    procedures.

     

    Surgeons frequently underestimate and undertreat
    postoperative pain.

      

    A safe and effective local agent capable of
    providing sustained analgesia for 6 weeks or more is
    highly desirable, and may well influence hospital
    stay, return to work, and, certainly, patient
    satisfaction.

     

    The originator of the paste has cautioned that the
    agent has the potential – to act as a hyperosmolar
    agent, producing a sometimes painful but sterile and
    self-limiting subcutaneous fluid collection.

     

    More research is needed before analgesic epidural
    paste can be recommended.

       

  • Heyland
    DK, for the Canadian Critical Care Trials Group
    [Queen’s Univ, Kingston, Ont, Canada; et al]

    The Clinical Utility of Invasive Diagnostic
    Techniques in the Setting of Ventilator – Associated
    Pneumonia


    Chest
    115: 1076-1084, 1999

     

    Ventricular-associated
    pneumonia [VAP] is often diagnosed on clinical
    grounds alone and contributes to the morbidity,
    mortality and costs of caring for critically ill
    patients. Overdiagnosis may be disastrous with the
    use of needless antibiotics and the delay in
    recognition of the ‘true’ diagnosis.

     

    The utility of invasive investigations like
    bronchoscopy, with protected brush catheter [PBC]
    bronchoalveolar lavage [BAL] was evaluated in 92
    patients receiving ventilatory support 
    with a clinical suspicion of VAP.

     

    The
    results showed that VAP was often overdiagnosed
    after BAL or PBC after these procedures. Patients
    received fewer antibiotics. Both groups had similar
    duration of mechanical ventilation and ICU stay.
    Those who underwent PBC/BAL had a lower mortality.

     

    Invasive diagnostic testing may boost physicians
    confidence in the diagnosis and management of VAP.

       

  • PCA Kam [University of South Wales, Australia]


    Occupational Stress in Anaesthesia


    Anaesth Intensive Care 25: 686-690

       


    Stress appears to be more common in anesthetists than in other medical

      


    Practitioners, Sources and effects of stress are examined and methods of dealing with occupational stress are suggested.

      


    Personality traits of 231 anesthetists were studied; 20% were classified as unstable, demonstrating the traits of individuals who had attempted suicide. Major sources of stress included lack of control [42%], professional relationship [ 25%], work overload [23%] administrative responsibility [41%], conflict between demands at work and home [35%], litigation [2.8%] and peer review and continuing medical education [3.9%].

      


    Coping strategies are introduced after initial alarm reactions but these are effective only for a short term. Prolonged stress can lead to exhaustion, physical and emotional symptoms, mental dysfunction and ultimately burnout.

      


    Suicide rates for physicians are 2 to 6 times higher than the rates for general population. Suicide rates for anesthetists are 3 to 4 times higher than those for physicians in general.

      


    Anesthetists need help to deal with problems by way of stress management seminars and better time management, encouragement to share experiences and emotional problems with a colleague or peer; personal counseling and workshops to cope with high levels of stress they are experiencing.

      


    Awareness of occupational stress is important to achieve the goal of early intervention and prevention of catastrophes.

       

  • R
    Burstal , F Wegener, C Hayes, et al

    Epidural
    Analgesia; Prospective Audit of 1062 Patients

    Anaesth
    Intensive Care 26 : 165-172, 1998

     

    The
    side effects and complications of epidural analgesia
    were prospectively determined.

     

    A
    survey of 1060 surgical patients aged 6 weeks to 92
    years, who received at least one epidural analgestic
    infusion, was conducted over 2 years. Success or
    failure of analgesia, side effects and complications
    were recorded.

     

    Local
    anesthetic and an opioid mixture were used in 1131
    infusions, and opioids alone in 160 infusions. 
    Infusions sites included 805 thoracic, 485
    lumbar and 1 cervical.  Duration of infusion averaged 2.7 days and ranged from 1 to
    15 days. Catheter related complications requiring
    early removal included 139 dislodgements, 57
    catheter site inflammations, 40 catheter leaks, 5
    catheter site infections requiring antibiotics, 3 IV
    catheter migrations and 1 subarachnoid catheter
    migration. There were 347 major and 99 minor
    technique related complications. Patients receiving
    0.125% bupivacaine and fentanyl had significantly
    more leg weakness and anesthesia failure than those
    receiving 0.25% bupivacaine and fentanyl : the
    latter had significantly more pruritus and
    respiratory depression and significantly more
    required naloxone. One third of the 14% anesthesia
    failures were converted to satisfactory blocks but
    the remaining had their catheters replaced or had
    another analgesia technique performed.

     

    Although
    epidural anesthesia can be used successfully and
    safely in most patients as many as 20% will not
    receive adequate analgesia. Accidental dislodgment
    of the catheter is a major cause of analgesia
    failure.

       

  • A
    Gottschalk, DS Smith, DR Jobes, et al

    Preemptive
    Epidural Analgesia and Recovery from Radical
    Prostatectomy : A Randomised Controlled Trial


    JAMA
    279 : 1076-1082, 1998

     

    Pain
    perception can be decreased by inhibiting CN 
    S sensitization before the painful stimulus
    is introduced. However, whether such 
    preemptive analgesia has proven clinical
    efficacy is a matter of controversy. The authors
    compared postoperative pain and other outcome
    measures after radical prostatectomy in patients who
    either did or did not receive preemptive analgesia.

      

    Preoperative
    epidural analgesia significantly reduced
    postoperative pain till well after discharge and
    helped patients resume normal activities earlier.

       

  • E
    Worwag, GW Chodak

    Overnight
    Hospitalization After Radical Prostatectomy : The
    impact of two pathways on patient satisfaction,
    Length of Hospitalization and Morbidity.


    Radical
    Protatectomy

    Anesth
    analg 87  62-67,
    1998

     

    Emphasis
    on cost control has spurred attempts to decrease
    hospital stays. 
    The efficacy of overnight hospitalization for
    radical prostatectomy using complications and
    patient satisfaction as measures were reported for
    100 consecutive patients.

     

    A
    standard retopubic radical prostatectomy was
    performed on all patients under epidural anesthesia
    followed by epidural morphine [ n=47] or combined
    spinal anesthesia using bupivacaine and fentanyl
    followed by 10 to 20 mg of IM methadone [n=53].
    Length of hospital stay, postsurgical morbidity and
    patient satisfaction were compared.

     

    Duration
    of surgery was significantly longer for the
    methadone group as compared to the morphine group.
    The median period of hospital stay was same
    for both groups [ 1.2 to 1.34 days].  Only 17% of the patients stayed longer than one night.
    There were no complications attributable to
    surgery, anesthesia or analgesia. Only 21% of
    patients believed their stay was too short.

       

  • Shende
    D, Cooper GM, Bowden (AIIMS, New Delhi, India;
    Birmingham Women’s Hosp, England)

    The
    Influence of Intrathecal Fentanyl on the
    Characteristics of Subarachnoid Block for Caesarean
    Section.


    Anaesthesia
    53: 706-710, 1998

     

    Objective
    : Whether the addition of an opioid 
    to intrathecal solutions improves
    intraoperative comfort is unknown. The effect of
    adding 15µg fentanyl to hyperbaric 0.5% bupivacaine
    given intrathecally for elective cesarean section
    was investigated in a randomized, double-blind
    study.

     

    Methods:
    Either 15 µg fentanyl or 0.3cc preservative-free
    0.9% saline was added to 2.5mL hyperbaric 0.5%
    bupivacaine for subarachnoid block and administered
    to 40 healthy laboring women undergoing elective
    cesarean section.

     

    Results
    : Onset times for the fentanyl group and the saline
    group were similar. Whereas
    ephedrine and morphine requirements were similar,
    the fentanyl group did not require morphine until
    significantly later than the saline group, and the
    duration of blockade was significantly longer in the
    fentanyl group than in the saline group.
    Seven of the saline group and none of the
    fentanyl group experienced discomfort.
    Neonatal outcomes and maternal side effects
    were similar for the 2 groups.

     

    Conclusions
    : Addition of fentanyl to intrathecally administered
    0.5% bupivacaine improved the quality and duration
    of analgesia.

        

  • Ngan
    Kee WD, Khaw KS, Ma ML, et al (Chinese Univ of Hong
    Kong)

    Postoperative
    Analgesic Requirement After Cesarean Section: A
    Comparison of Anesthetic Induction With Ketamine or
    Thiopental.

    Anesth
    Analg 85: 1294-1298, 1997

     

    Editorial
    comment by S.E. Abram, MD
    :
    The effect of preincisional ketamine on
    postoperative analgesia and opiate requirement was
    quite modest in this study.
    This is not surprising because, only a single
    small dose was administered.
    This study should be repeated, using higher
    doses and continued intraoperative administration,
    in patients undergoing surgery that typically
    produces substantial pain, e.g. lateral thoracotomy.

        

  • Heyland
    DK, for the Canadian Critical Care Trials Group [Queen’s Univ, Kingston, Ont, Canada; et al]

    The Clinical Utility of Invasive Diagnostic Techniques in the Setting of Ventilator -Associated Pneumonia

    Chest 115: 1076-1084, 1999



    Ventricular-associated pneumonia [VAP] is often diagnosed on clinical grounds alone and contributes to the morbidity, mortality and costs of caring for critically ill patients. Over diagnosis may be disastrous with the use of needless antibiotics and the delay in recognition of the ‘true’ diagnosis.





    The utility of invasive investigations like bronchoscopy, with protected brush catheter [PBC] bronchoalveolar lavage [BAL] was evaluated in 92 patients receiving ventilatory support with a clinical suspicion of VAP.



    The results showed that VAP was often over diagnosed after BAL or PBC after these procedures. Patients received fewer antibiotics. Both groups had similar duration of mechanical ventilation and ICU stay. Those who underwent PBC/BAL had a lower mortality.



    Invasive diagnostic testing may boost physicians confidence in the diagnosis and management of VAP.

      

  • Urwin SC, Parker MJ, et al (Peterborough District Hosp, UK)

    General Versus Regional Anaesthesia for Hip Fracture Surgery: A Meta-analysis of Randomized Trials

    Br J Anaesth 84: 450-455, 2000

      

    A meta-analysis performed on 15 randomized trials included 2162 patients, in whom different anesthetic techniques used during hip fracture repair were compared. Morbidity and mortality rates were also studied.

     

    The incidence of deep vein thrombosis and survival at 1 month were significantly lower with regional anesthesia than with general anesthesia (GA). The length of operation was slightly but significantly shorter with GA than with regional anesthesia.

      

    The authors conclude that the use of regional anesthesia for hip fracture repair is associated with lower morbidity, fewer early deaths and a reduced tendency to deep vein thrombosis.

       




 

 

Specialty Spotlight

 

 
Anaesthesia
   

 

  • Tait AR, Pandit UA, Voepel-Lewis T, et al
    Use of Laryngeal Mask Airway in Children with Upper Respiratory Tract Infections: A Comparison with Endotracheal Intubation
    Anesth Analg 86:706-711, 1998
       
    There is debate over whether to proceed with anesthesia in children with upper respiratory infections [URI] who are sent for elective surgery.  Endotracheal tube placement [ETT] may increase the risk of complications in children with URI.  The laryngeal mask airway [ LMA ] provides a new approach to airway management.  This study compares the LMA with ETT in children with URI.
     
    The randomized trial included 82 children, aged 3 months to 16 years, undergoing elective surgery with URI.  Those with lower respiratory tract infection were excluded.  Half of the patients were managed with LMA and half with ETT, both placed under standard techniques.  Both groups underwent induction of anesthesia with nitrous oxide, oxygen, and halothane.  Patients were monitored from induction through postanesthesia for complications such as cough, laryngospasm, bronchospasm, breath-holding, and arrhythmias.  Arterial oxygen desaturation [pulse oxymetry of less than 90%] was considered a major desaturation event.
       
    The LMA and ETT groups were comparable in terms of age, anesthesia and surgery times, number of tube placement attempts, and URI symptoms. The two methods produced similar incidence of cough, breath-holding, excessive secretions and arrythmias. There was also no difference in the incidence of laryngospasm, although one patient with an ETT required muscle relaxant for this complication. Mild bronchospasm occurred in 12% in the ETT group and none in the LMA group.  Major desaturation events were also more common with ETT, 12.5% vs 0%. Respiratory complications were also more in the ETT group, 35 vs 19 in the LMA group. Still, the respiratory complications were easily managed in all with no adverse sequelae. Thus overall LMA offers a better choice than ETT in the anesthetic management of children with URI.
        

  • Hogan G
    Epidural Catheter Tip Position and Distribution of Injectate Evaluated by Computed Tomography
    Anesthesiology 90: 964-970, 1999
      
    Asymmetric epidural blockade is common, occurring in as many as 21% of patients. Patterns of asymmetric distribution have not been studied.  Catheter positions and patterns of circumferential distribution of solution injected during routine epidural anesthesia were assessed by means of CT.
     
    20 women, average age 55 years, undergoing brachytherapy for cervical cancer, under epidural anesthesia were studied. A continuous infusion of bupivacaine and fentanyl was provided and adjusted throughout the course of brachytherapy. The level of analgesia was determined by pin scratch, and ability to flex ankles, knees, and hips was documented twice daily.  Four hours after surgery, CT was performed to guide placement of radiation sources. The tip of the epidural catheter was identified, contrast material injected, and a series of images was obtained. The images were examined by evaluators who were blinded to the extent of analgesia.
       
    Results showed the catheter was placed at the desired level in 8 patients, higher than intended in 11 and through the posterior epidural fat in 1 patient.  Eight catheter tips were in or near the posterior epidural space, 9 in the intervertebral foramina and two in the paravertebral tissues lateral to the intervertebral foramina. Patterns of spread were not consistent, although most showed spread anterior to the dura, and most showed posterior and lateral spread. In most patients, the contrast material left asymmetrically through the intervertebral foramina into the psoas muscles. Air bubbles and fat arrested distribution of analgesia in two patients.  Layering of the solution without foraminal spread was seen in 9 of 15 patients after a 4 mL injection, and in 5 of 19 patients after a 10 mL injection. Subdural accumulation was noted in one patient, and leakage through the ligamentum flavum in two.  Most patients had block levels that differed by 2 or fewer segments, 2 patients had maximum difference of segments and one had a difference of 4 segments. Thus catheter position and analgesia distribution vary greatly from patient to patient but adequate analgesia is provided in most cases.
       

  • Ziser A, Plevak DJ, Wiesner RH, et al


    Morbidity and Mortality in Cirrhotic Patients undergoing Anesthesia and Surgery
    Anesthesiology 90: 42-53, 1999
     
    Patients with cirrhosis of liver who undergo anesthesia and surgery have an increased mortality rate. Factors that might predict perioperative complications and death in such patients were retrospectively investigated.
     
    Records of 733 patients [338 women], aged 18 to 87 years, undergoing surgery, over a 11 year period, were reviewed for demographic information and concurrent medical conditions. Patients were followed up 2.7 to 13.7 years. A questionnaire was mailed to living patients, asking about their health and whether or not they had had a liver transplant; those who had a liver transplant were excluded from the study.
      
    Results showed, postoperative complications, most commonly pneumonia, occurred in 222 patients [30.1%]. There were 72 in hospital deaths [9.8%], and 13 out-of-hospital deaths [1.8%], within 30 days of surgery.  Most of the deaths occurred in the immediate post-operative period; 8 variables were associated with death and included male sex, a high Child-Pugh score, ascites, cryptogenic cirrhosis, elevated creatinine level, preoperative infection, a high ASA status, and respiratory surgery.
       

  • White CM, Dunn A, Tsikouris J, et al [Hartford Hospital, Conn., Univ of Connecticut, Storrs]
    An Assessment of the Safety of Short-Term Amiodarone Therapy in Cardiac Surgical Patients with Fentanyl Isoflurane Anesthesia
    Anesth Analg 89: 585-589, 1999
     
    Chronic amiodarone use, in combination with fentanyl anesthesias, may cause atrioventricular blockade, symptomatic bradycardia, sinus arrest, and severe hypotension. The effect of short-term amiodarone use has not been investigated. The effect on hemodynamics of fentanyl-containing anesthesia, administered to elderly patients receiving short-term amiodarone therapy before coronary artery bypass graft [CABG] or vascular surgery, was investigated in a prospective, randomized, double-blind, placebo-controlled trial.
     
    Elderly CABG patients were randomly allocated to receive amiodarone 3.4 g over 5 days, or 2.2 g over 24 hours [n=45] or placebo [n=39], before CABG. Fluid balance, use of dopamine, use of vaso-pressor catecholamines, and use of phospho- diasterase inhibitor or intra-aortic balloon pump were recorded.  Systolic, diastolic and central venous pressures were measured, before anesthesia, before cardiopulmonary bypass [CPB] and after CPB. Heart rates were recorded before induction of anesthesia and after CPB.
     
    Results showed fluid status increase by 2L in 2 [4.4%] amiodarone patients and in 4 [10.3%] placebo patients. No patient required dopamine or an intra-aortic baloon pump. Epinephrine or derivative was administered to 8 [17.8%] amiodarone and 5 [12.8%] placebo patients and milrinone to 1 [2.2%] amiodarone and 2 [5.1%] placebo patients. Preanesthesia and post PCB systolic blood pressure, were significantly lower in amiodarone patients.  Further, amiodarone patients received less fluid and had a lower net increase in fluid status, than the placebo patients, although the differences were not significant.
      
    Thus short term amiodarone therapy does not lead to hemodynamic instability in CABG patients receiving fentanyl anesthesia regimens.
       

  • Webster AC, Morley-Forster PK, Janzen V, et al [ Univ of Western Ontario, London]
    Anesthesia for Intranasal Surgery : A Comparison Between Tracheal Intubation and the Flexible Reinforced Laryngeal Mask Airway
    Anesth Analg 88: 421-425, 1999
     
    Prototype flexible reinforced laryngeal mask airways [LMAs], do not directly stimulate the larynx and therefore reduce the respiratory and cardiovascular reflex responses to placement and removal. A study was undertaken to determine whether the use of flexible reinforced LMA for anesthesia in intranasal surgery can reduce the incidence of airway complications without compromising airway protection as compared with tracheal intubation.
     
    Outpatients undergoing endoscopic intranasal surgery or septoplasty were randomly allocated to size 4 flexible reinforced LMA with spontaneous breathing and removal while awake [group 1, n=35], tracheal intubation with cuffed endotracheal tube with intermittent positive pressure ventilation and extubation while awake [ group 2, n=34], and tracheal intubation with spontaneous breathing and extubation while deeply anesthetized [group 3, n=32]. Incidence of coughing, sore throat, hoarseness, blood loss, and oxyhemoglobin desaturation at removal were recorded.
     
    The incidence of laryngospasm was 0 in group 1, 6% in group 2, and 19% in group 3. The incidence of oxyhemoglobin desaturation was 0 in group 1, 26% in group 2, and 16% in group 3. The time between discontinuation of anesthesia and departure from the operation room was significantly less in group 1 than in group 2  and group 3 [10.74 vs 14.85 vs 12.16 min]. Whereas all groups had a high incidence of sore throat on the first postoperative day, the incidence of hoarseness was significantly lower in group 1 than in groups 2 and 3.
     
    Thus flexible, reinforced LMA is safe and more effective than endotracheal intubation for use during intranasal surgery.
       

  • Lowinger D, Benjamin B, Gadd L. [St Luke’s  Hospital, Sydney, Australia]
    Recurrent Laryngeal Nerve Injury Caused by a Laryngeal Mask Airway
    Anaesth Intensive Care 27: 202-205, 1999
     
    There are reports of laryngeal nerve damage after the use of laryngeal mask airways [LMA]. A rare case of permanent unilateral vocal cord paralysis that required thyroplasty for voice restoration is reported.
     
    Male, 44, employed as announcer, underwent ligation of varicose veins. After anesthesia was induced, a size 4 LMA was inserted. The cuff was inflated to 20 mL of air but the cuff pressure was not monitored.  After uneventful surgery, the LMA was removed. Over the next 24 hours patient experienced dysphonia without pain, which went on to aphonia by day 2. The left vocal cord was seen to be immobile with no other neurological abnormality. At 6 months left cord paralysis was confirmed without arytenoid cartilage dislocation or other glottic disorder. A trial injection of Gelfoam at 9 months restored good voice for a few weeks. At 12 months, thryroplasty was performed with a 4 mm hydoxyapatite prosthesis, and the patient’s voice improved though the cord paralysis persisted.
     
    Whereas LMA is generally safe and effective, in rare cases it can lead to persistent dysphonia, probably as a result of extensive ischemia with demyelination and neural loss.
      

  • Hurlbert RJ, Theodore N, Drabier JB, et al [Univ of Calgary, Alta; St Joseph’s Hosp, Phoenix, Ariz]
    A Prospective Randomized Double- Blind Controlled Trial to Evaluate the Efficacy of an Analgesic Epidural Paste Following Lumbar Decompressive Surgery
    J Neurosurg : Spine 90: 191-197, 1999
     
    Pain management after lumbar surgery currently relies on systemic narcotics, which carry significant side effects and can delay, return to activities.
     
    An analgesic paste containing morphine and methylprednisolone was evaluated for its ability to control postoperative pain after lumbar spine decompression.
     
    Applied directly to the dura just before wound closure, an analgesic epidural paste can significantly improve pain control after lumbar spine decompressive surgery.
     
    Analgesic paste is a safe and effective treatment that may become a new standard of care for patients undergoing lumbar decompression and other surgical procedures.
     
    Surgeons frequently underestimate and undertreat postoperative pain.
      
    A safe and effective local agent capable of providing sustained analgesia for 6 weeks or more is highly desirable, and may well influence hospital stay, return to work, and, certainly, patient satisfaction.
     
    The originator of the paste has cautioned that the agent has the potential – to act as a hyperosmolar agent, producing a sometimes painful but sterile and self-limiting subcutaneous fluid collection.
     
    More research is needed before analgesic epidural paste can be recommended.
       

  • Heyland DK, for the Canadian Critical Care Trials Group [Queen’s Univ, Kingston, Ont, Canada; et al]
    The Clinical Utility of Invasive Diagnostic Techniques in the Setting of Ventilator – Associated Pneumonia
    Chest 115: 1076-1084, 1999
     
    Ventricular-associated pneumonia [VAP] is often diagnosed on clinical grounds alone and contributes to the morbidity, mortality and costs of caring for critically ill patients. Overdiagnosis may be disastrous with the use of needless antibiotics and the delay in recognition of the ‘true’ diagnosis.
     
    The utility of invasive investigations like bronchoscopy, with protected brush catheter [PBC] bronchoalveolar lavage [BAL] was evaluated in 92 patients receiving ventilatory support  with a clinical suspicion of VAP.
     
    The results showed that VAP was often overdiagnosed after BAL or PBC after these procedures. Patients received fewer antibiotics. Both groups had similar duration of mechanical ventilation and ICU stay. Those who underwent PBC/BAL had a lower mortality.
     
    Invasive diagnostic testing may boost physicians confidence in the diagnosis and management of VAP.
       

  • PCA Kam [University of South Wales, Australia]
    Occupational Stress in Anaesthesia
    Anaesth Intensive Care 25: 686-690
       
    Stress appears to be more common in anesthetists than in other medical
      
    Practitioners, Sources and effects of stress are examined and methods of dealing with occupational stress are suggested.
      
    Personality traits of 231 anesthetists were studied; 20% were classified as unstable, demonstrating the traits of individuals who had attempted suicide. Major sources of stress included lack of control [42%], professional relationship [ 25%], work overload [23%] administrative responsibility [41%], conflict between demands at work and home [35%], litigation [2.8%] and peer review and continuing medical education [3.9%].
      
    Coping strategies are introduced after initial alarm reactions but these are effective only for a short term. Prolonged stress can lead to exhaustion, physical and emotional symptoms, mental dysfunction and ultimately burnout.
      
    Suicide rates for physicians are 2 to 6 times higher than the rates for general population. Suicide rates for anesthetists are 3 to 4 times higher than those for physicians in general.
      
    Anesthetists need help to deal with problems by way of stress management seminars and better time management, encouragement to share experiences and emotional problems with a colleague or peer; personal counseling and workshops to cope with high levels of stress they are experiencing.
      
    Awareness of occupational stress is important to achieve the goal of early intervention and prevention of catastrophes.
       

  • R Burstal , F Wegener, C Hayes, et al
    Epidural Analgesia; Prospective Audit of 1062 Patients
    Anaesth Intensive Care 26 : 165-172, 1998
     
    The side effects and complications of epidural analgesia were prospectively determined.
     
    A survey of 1060 surgical patients aged 6 weeks to 92 years, who received at least one epidural analgestic infusion, was conducted over 2 years. Success or failure of analgesia, side effects and complications were recorded.
     
    Local anesthetic and an opioid mixture were used in 1131 infusions, and opioids alone in 160 infusions.  Infusions sites included 805 thoracic, 485 lumbar and 1 cervical.  Duration of infusion averaged 2.7 days and ranged from 1 to 15 days. Catheter related complications requiring early removal included 139 dislodgements, 57 catheter site inflammations, 40 catheter leaks, 5 catheter site infections requiring antibiotics, 3 IV catheter migrations and 1 subarachnoid catheter migration. There were 347 major and 99 minor technique related complications. Patients receiving 0.125% bupivacaine and fentanyl had significantly more leg weakness and anesthesia failure than those receiving 0.25% bupivacaine and fentanyl : the latter had significantly more pruritus and respiratory depression and significantly more required naloxone. One third of the 14% anesthesia failures were converted to satisfactory blocks but the remaining had their catheters replaced or had another analgesia technique performed.
     
    Although epidural anesthesia can be used successfully and safely in most patients as many as 20% will not receive adequate analgesia. Accidental dislodgment of the catheter is a major cause of analgesia failure.
       

  • A Gottschalk, DS Smith, DR Jobes, et al
    Preemptive Epidural Analgesia and Recovery from Radical Prostatectomy : A Randomised Controlled Trial
    JAMA 279 : 1076-1082, 1998
     
    Pain perception can be decreased by inhibiting CN  S sensitization before the painful stimulus is introduced. However, whether such  preemptive analgesia has proven clinical efficacy is a matter of controversy. The authors compared postoperative pain and other outcome measures after radical prostatectomy in patients who either did or did not receive preemptive analgesia.
      
    Preoperative epidural analgesia significantly reduced postoperative pain till well after discharge and helped patients resume normal activities earlier.
       

  • E Worwag, GW Chodak
    Overnight Hospitalization After Radical Prostatectomy : The impact of two pathways on patient satisfaction, Length of Hospitalization and Morbidity.
    Radical Protatectomy
    Anesth analg 87  62-67, 1998
     
    Emphasis on cost control has spurred attempts to decrease hospital stays.  The efficacy of overnight hospitalization for radical prostatectomy using complications and patient satisfaction as measures were reported for 100 consecutive patients.
     
    A standard retopubic radical prostatectomy was performed on all patients under epidural anesthesia followed by epidural morphine [ n=47] or combined spinal anesthesia using bupivacaine and fentanyl followed by 10 to 20 mg of IM methadone [n=53]. Length of hospital stay, postsurgical morbidity and patient satisfaction were compared.
     
    Duration of surgery was significantly longer for the methadone group as compared to the morphine group. The median period of hospital stay was same for both groups [ 1.2 to 1.34 days].  Only 17% of the patients stayed longer than one night. There were no complications attributable to surgery, anesthesia or analgesia. Only 21% of patients believed their stay was too short.
       

  • Shende D, Cooper GM, Bowden (AIIMS, New Delhi, India; Birmingham Women’s Hosp, England)
    The Influence of Intrathecal Fentanyl on the Characteristics of Subarachnoid Block for Caesarean Section.
    Anaesthesia 53: 706-710, 1998
     
    Objective : Whether the addition of an opioid  to intrathecal solutions improves intraoperative comfort is unknown. The effect of adding 15µg fentanyl to hyperbaric 0.5% bupivacaine given intrathecally for elective cesarean section was investigated in a randomized, double-blind study.
     
    Methods: Either 15 µg fentanyl or 0.3cc preservative-free 0.9% saline was added to 2.5mL hyperbaric 0.5% bupivacaine for subarachnoid block and administered to 40 healthy laboring women undergoing elective cesarean section.
     
    Results : Onset times for the fentanyl group and the saline group were similar. Whereas ephedrine and morphine requirements were similar, the fentanyl group did not require morphine until significantly later than the saline group, and the duration of blockade was significantly longer in the fentanyl group than in the saline group. Seven of the saline group and none of the fentanyl group experienced discomfort. Neonatal outcomes and maternal side effects were similar for the 2 groups.
     
    Conclusions : Addition of fentanyl to intrathecally administered 0.5% bupivacaine improved the quality and duration of analgesia.
        

  • Ngan Kee WD, Khaw KS, Ma ML, et al (Chinese Univ of Hong Kong)
    Postoperative Analgesic Requirement After Cesarean Section: A Comparison of Anesthetic Induction With Ketamine or Thiopental.
    Anesth Analg 85: 1294-1298, 1997
     
    Editorial comment by S.E. Abram, MD: The effect of preincisional ketamine on postoperative analgesia and opiate requirement was quite modest in this study. This is not surprising because, only a single small dose was administered. This study should be repeated, using higher doses and continued intraoperative administration, in patients undergoing surgery that typically produces substantial pain, e.g. lateral thoracotomy.
        

  • Heyland DK, for the Canadian Critical Care Trials Group [Queen’s Univ, Kingston, Ont, Canada; et al]
    The Clinical Utility of Invasive Diagnostic Techniques in the Setting of Ventilator -Associated Pneumonia
    Chest 115: 1076-1084, 1999

    Ventricular-associated pneumonia [VAP] is often diagnosed on clinical grounds alone and contributes to the morbidity, mortality and costs of caring for critically ill patients. Over diagnosis may be disastrous with the use of needless antibiotics and the delay in recognition of the ‘true’ diagnosis.


    The utility of invasive investigations like bronchoscopy, with protected brush catheter [PBC] bronchoalveolar lavage [BAL] was evaluated in 92 patients receiving ventilatory support with a clinical suspicion of VAP.

    The results showed that VAP was often over diagnosed after BAL or PBC after these procedures. Patients received fewer antibiotics. Both groups had similar duration of mechanical ventilation and ICU stay. Those who underwent PBC/BAL had a lower mortality.

    Invasive diagnostic testing may boost physicians confidence in the diagnosis and management of VAP.
      

  • Urwin SC, Parker MJ, et al (Peterborough District Hosp, UK)
    General Versus Regional Anaesthesia for Hip Fracture Surgery: A Meta-analysis of Randomized Trials
    Br J Anaesth 84: 450-455, 2000
      
    A meta-analysis performed on 15 randomized trials included 2162 patients, in whom different anesthetic techniques used during hip fracture repair were compared. Morbidity and mortality rates were also studied.
     
    The incidence of deep vein thrombosis and survival at 1 month were significantly lower with regional anesthesia than with general anesthesia (GA). The length of operation was slightly but significantly shorter with GA than with regional anesthesia.
      
    The authors conclude that the use of regional anesthesia for hip fracture repair is associated with lower morbidity, fewer early deaths and a reduced tendency to deep vein thrombosis.
       

 

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