Anesthesia and analgesia
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The authors present a rare case of a cervical cord dysfunction after uncomplicated coronary artery bypass grafting. The preoperative neurological examination did not reveal any abnormalities; however, the postoperative magnetic resonance image showed significant spinal canal stenosis at the same levels as high signal lesions. Although the pathophysiological basis of the case was impossible to determine retrospectively, it seems probable that placing the neck in an extended position during surgery might have aggravated a preexisting spinal canal stenosis to produce cervical injury. ⋯ The authors present a rare case of tetraplegia after coronary artery bypass grafting. It is suggested that neck extension during surgery might have aggravated an occult preexisting cervical spinal canal stenosis to produce cervical injury.
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Anesthesia and analgesia · Oct 2003
Case ReportsSciatic nerve palsy after total hip arthroplasty in a patient receiving continuous lumbar plexus block.
We report a case of late-onset postoperative sciatic palsy after total hip arthroplasty in a 30-yr-old man with congenital hip dysplasia. The patient was receiving continuous lumbar plexus blockade and had received low-molecular-weight heparin 3 h before the onset of symptoms. Anatomic distinction between the nerve block and the sciatic palsy facilitated rapid diagnosis and treatment of a periarticular hematoma, with resulting neurologic recovery. This case illustrates that, with the expanded role of regional anesthetic techniques in acute pain management, the finding of a new postoperative deficit must be jointly investigated by both anesthesiologists and surgeons. Timely and open communication between services is critical because rapid intervention may be essential to achieving full recovery of an affected nerve. ⋯ A case is presented of sciatic palsy developing after total hip arthroplasty in a patient receiving a continuous lumbar plexus block. The case highlights various issues in the use of continuous peripheral nerve blocks for postoperative analgesia.
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Anesthesia and analgesia · Oct 2003
Randomized Controlled Trial Clinical TrialIntraoperative intravenous ketamine in combination with epidural analgesia: postoperative analgesia after renal surgery.
We designed this double-blinded, randomized, controlled study to evaluate the effect of small-dose ketamine IV in combination with epidural morphine and bupivacaine on postoperative pain after renal surgery. An epidural catheter was inserted, and the administration of morphine and bupivacaine was started before surgery. Forty patients were assigned to one of two groups (ketamine or control). The ketamine group was administered a ketamine bolus and infusion during surgery. The median visual analog pain scale (VAS) scores at rest were significantly lower in the ketamine group during the first 6 h (P < 0.01). VAS pain scores on coughing were also significantly lower in the ketamine group (P < 0.01). Cumulative postoperative total analgesic consumption was less in the ketamine group on Days 1 and 2 (P < 0.001). The first analgesic demand time was shorter in the control group (9.2 +/- 11.5 min) than in the ketamine group (22.3 +/- 17.1 min) (P < 0.0001). The incidence of nausea and pruritus was more frequent in the control group (P < 0.05). In conclusion, postoperative analgesia was more effective when spinal cord and brain sensitization were blocked by a combination of epidural morphine/bupivacaine and IV ketamine. ⋯ Renal nociception conducted multisegmentally by both the spinal nerves (T10 to L1) and the vagus nerve cannot be blocked by epidural analgesia alone. We demonstrated that IV ketamine had an improved analgesic or opioid-sparing effect when it was combined with epidural bupivacaine and morphine after renal surgery.
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Anesthesia and analgesia · Oct 2003
Randomized Controlled Trial Clinical TrialSevoflurane requirements to suppress responses to transcutaneous electrical stimulation during epidural anesthesia with 0.5% and 1% lidocaine.
We sought to determine general anesthetic requirements to suppress skin vasomotor reflex (SVmR) and pupillary dilation (PD) in response to transcutaneous electrical stimulation (TES) during combined epidural-general anesthesia. Thirty-five patients undergoing lower abdominal surgery were randomly divided into 2 groups to epidurally receive 0.5% (Group 1) or 1% lidocaine (Group 2) with sevoflurane anesthesia. A bolus injection of either lidocaine was followed by the infusion of the same solution, and the central dermatomal level of loss of cold sensation (C) was determined. After the induction of general anesthesia with 5% sevoflurane and 67% nitrous oxide, nitrous oxide was discontinued, and sevoflurane concentration was decreased. TES was given at both site C and site three dermatomal segments (U) cephalad to C to determine the end-tidal sevoflurane concentration required to suppress SVmR and PD. End-tidal sevoflurane concentration that suppressed both responses was larger in Group 1 than in Group 2 at both sites and was larger at site U than at site C in both groups. We conclude that sevoflurane requirements to suppress SVmR and PD in response to TES during combined epidural-general anesthesia are different depending on the concentration of lidocaine and the site where surgical stimulation is applied. ⋯ We evaluated sevoflurane requirements to suppress skin vasomotor reflex and pupillary dilation in response to a transcutaneous electrical stimulation at the surgical site during combined epidural-general anesthesia. Our results indicate that when epidural anesthesia is combined, general anesthetic requirements decrease depending on the lidocaine concentration for epidural anesthesia and the site where surgical stimulation is applied.
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Anesthesia and analgesia · Oct 2003
Clinical TrialThe effect of pain on health-related quality of life in the immediate postoperative period.
The hypothesis of this study was to determine if the severity of postoperative pain would affect patients' health-related quality of life (HRQL) in the immediate postoperative period (within 2 wk of surgery). We designed this study as a prospective, nonrandomized observational trial in a tertiary academic care center. Patients undergoing elective total hip or knee replacement surgery were eligible. Patients received a standardized intraoperative general or epidural anesthetic followed by IV patient-controlled analgesia or patient-controlled epidural analgesia. Short Form (SF)-12, visual analog scores for pain at rest and pain with activity, nausea, and itching were assessed on postoperative days 1-5, 7, and 14. The severity of pain correlated with a decrease in both the physical and mental component of the SF-12. The severity of nausea correlated with a decrease in the mental but not physical component of the SF-12. The severity of itching did not correlate with a change in the SF-12. Our findings suggest that an increase in postoperative pain will decrease a patient's quality of life in the immediate postoperative period; however, several methodologic issues exist when assessing HRQL in the immediate postoperative period. ⋯ Severity of postoperative pain may affect quality of life.