Anesthesia and analgesia
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Anesthesia and analgesia · Dec 2001
Case ReportsThe use of a "reverse" axis (axillary-interscalene) block in a patient presenting with fractures of the left shoulder and elbow.
A patient presented for surgery to repair a fractured left shoulder and elbow and requested regional anesthesia. Most upper extremity operations require a single brachial plexus nerve block. The position of the two fractures however required the use of two separate approaches, an interscalene and an axillary approach.
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Anesthesia and analgesia · Dec 2001
Randomized Controlled Trial Comparative Study Clinical TrialPatient-controlled epidural analgesia after abdominal surgery: ropivacaine versus bupivacaine.
In this randomized, double-blinded study we sought to assess the analgesic efficacy of ropivacaine and bupivacaine in combination with sufentanil and the efficacy of ropivacaine alone after major abdominal surgery. Sixty patients undergoing major abdominal surgery received standardized general anesthesia combined with epidural thoracic analgesia. They were allocated to one of three groups: the BS group received postoperative patient-controlled epidural analgesia with 0.125% bupivacaine plus 0.5 microg/mL sufentanil; the RS group received 0.125% ropivacaine plus 0.5 microg/mL sufentanil; and the R group received 0.2% ropivacaine, with the patient-controlled epidural analgesia device set at bolus 2-3 mL and background infusion 3-5 mL/h. Visual analog scale scores were significantly lower during coughing in the BS group compared with the RS and R groups and in the RS group compared with the R group. The BS group required significantly less local anesthetic (milligrams per day) during the first three postoperative days compared with the RS and R groups, and the RS group, significantly less than the R group. No major side effects were noted in any group. We conclude that, after major abdominal surgery, thoracic epidural analgesia was more effective with bupivacaine than with ropivacaine when these two local anesthetics are used in a mixture with sufentanil. Ropivacaine alone was less effective than ropivacaine in combination with sufentanil. ⋯ After major abdominal surgery, thoracic epidural analgesia was more effective with 0.125% bupivacaine than with 0.125% ropivacaine when these two local anesthetics were used in a mixture with 0.5 microg/mL sufentanil. Ropivacaine 0.2% alone was less effective than 0.125% ropivacaine combined with sufentanil.
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Anesthesia and analgesia · Dec 2001
Randomized Controlled Trial Clinical TrialThe efficacy of simulated intravascular test dose in sedated patients.
Sedation usually decreases the reliability of subjectively detecting an intravascular test dose, but the efficacies of objective hemodynamic and T-wave criteria remain undetermined. Sixty healthy patients were randomly assigned to receive IV midazolam in 1-mg increments until they were lightly sedated, fentanyl 2 microg/kg followed by incremental midazolam until they were similarly sedated, or no sedative (n = 20 each). Then, normal saline 3 mL was administered IV, followed 4 min later by 1.5% lidocaine 3 mL plus epinephrine 15 microg (1:200,000) in all subjects. Heart rate (HR), systolic blood pressure (SBP) measured by a radial arterial catheter, and lead II of the electrocardiogram were continuously recorded for 4 min after the saline and test dose injections. An IV test dose produced significant increases in HR and SBP and decreases in T-wave amplitude in all subjects. However, the mean maximum increase in HR in patients sedated with midazolam plus fentanyl (31 +/- 14 bpm [mean +/- SD]) was significantly less than in those administered midazolam alone or no sedative (42 +/- 12 and 44 +/- 10 bpm, respectively; P < 0.05). A sensitivity of 100% was obtained on the basis of the traditional HR criterion (positive if > or =20 bpm increase) in patients sedated with midazolam or no sedative, but it was 70% in those with midazolam plus fentanyl (P < 0.05 versus the other two groups). Irrespective of the treatment, sensitivities and specificities of 100% were obtained according to the SBP (positive if > or =15 mm Hg increase) and T-wave (positive if > or =25% decrease in amplitude) criteria. An increase in SBP and a decrease in T-wave amplitude are more reliable than an HR response for detecting accidental intravascular injection of the epinephrine-containing test dose in subjects sedated with midazolam and fentanyl. ⋯ To determine whether an epidural catheter is in a blood vessel, an epidural test dose containing 15 microg epinephrine is used. We found that an increase in systolic blood pressure and a decrease in T-wave amplitude seem to be more reliable than a heart rate change for detecting inadvertent intravascular injection of an epinephrine-containing test dose in patients sedated with midazolam and fentanyl.
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Anesthesia and analgesia · Dec 2001
Case ReportsBody temperature and diaphoresis disturbances in a patient with arachnoiditis.
Arachnoiditis, produced by different causes, is an inflammation of the sac containing the spinal cord and nerve roots. Patients with this disease have severe low back and leg pain, sweating and low grade fever. This case had aberrant skin temperature and sweating in different parts of the body.
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Anesthesia and analgesia · Dec 2001
Comparative StudyRegional anesthesia does not increase the risk of postoperative neuropathy in patients undergoing ulnar nerve transposition.
The use of regional anesthetic techniques in patients with preexisting neuropathies has been widely debated. The possibility of needle- or catheter-induced trauma, local anesthetic toxicity, or neural ischemia during regional blockade may place patients with underlying mechanical, ischemic, or metabolic neurologic derangements at increased risk of progressive neural injury. We evaluated the safety of regional versus general anesthesia in patients with a preexisting ulnar neuropathy undergoing ulnar nerve transposition. All patients (n = 360) who underwent ulnar nerve transposition at the Mayo Clinic from 1985 to 1999 were retrospectively studied. A general anesthetic was performed in 260 (72%) patients. The remaining 100 (28%) patients received an axillary block, including 64 patients in whom an ulnar paresthesia or nerve stimulator motor response was elicited at the time of block placement. Patient characteristics, the severity of preoperative ulnar nerve dysfunction, and surgical variables were similar between groups. Anesthetic technique did not affect neurologic outcome (new or worsening pain, paresthesias, numbness, or motor weakness) immediately after surgery or at 2 or 6 wk after surgery. All six patients in the Axillary Block group who reported new or worsening neurologic symptoms after surgery had received bupivacaine in combination with either an ulnar paresthesia or motor response. By using logistic regression, bupivacaine was identified as an independent risk factor for worsening of ulnar nerve function compared with other local anesthetics. We conclude that axillary blockade is a suitable anesthetic technique for this procedure. ⋯ The use of regional anesthetic techniques in patients with preexisting neuropathies has been widely debated. Theoretical concerns include the risk of progressive nerve damage from direct needle trauma or local anesthetic toxicity. This investigation, however, supports the safety of axillary blockade in patients with preexisting ulnar neuropathy undergoing ulnar nerve transposition.