Anesthesia and analgesia
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Anesthesia and analgesia · Mar 2004
Case ReportsTransesophageal echocardiographic diagnosis of a liver laceration accompanied by hemodynamic instability.
Transesophageal echocardiography (TEE) is a useful adjunct in the evaluation of trauma patients, particularly in the area of aortic injury and cardiac tamponade. Little has been written on the use of this modality in the evaluation of extra-cardiac injury. We present a case of a trauma patient in whom TEE was used to evaluate hemodynamic instability; during the course of the examination a previously undiagnosed liver laceration was identified. We report the diagnosis of a liver laceration in a trauma patient by novel use of the transesophageal echocardiographic imaging modality.
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Anesthesia and analgesia · Mar 2004
Case ReportsLumbar epidural blood patch to treat a large, symptomatic postsurgical cerebrospinal fluid leak of 5 weeks duration in a 3-year-old.
A 3-yr-old with B-cell lymphoma presented with a 5-wk history of 400 mL/day cerebrospinal fluid (CSF) leak, which precluded chemotherapy, after placement of an Omaya reservoir and drain. Surgical repair was unsuccessful. Symptoms included irritability, failure to eat and noncommunication. After lumbar epidural blood patch with 7 mL the symptoms resolved immediately, allowing recommencement of chemotherapy. Epidural blood patch should be considered as possible early treatment for CSF leaks. ⋯ An epidural blood patch successfully treated a large cerebrospinal fluid leak of long duration in a 3-yr-old. Considering the distress of such a leak to the patient, staff, and parents, epidural blood patch may be considered as an early treatment option.
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Anesthesia and analgesia · Mar 2004
When to release allocated operating room time to increase operating room efficiency.
We studied when allocated, but unfilled, operating room (OR) time of surgical services should be released to maximize OR efficiency. OR time was allocated for two surgical suites based on OR efficiency. Then, we analyzed real OR schedules. We added new hypothetical cases lasting 1, 2, or 3 h into OR time of the service that had the largest difference between allocated and scheduled cases (i.e., the most unfilled OR time) 5 days before the day of surgery. The process was repeated using the updated OR schedule available the day before surgery. The pair-wise difference in resulting overutilized OR time was calculated for n = 754 days of data from each of the two surgical suites. We found that postponing the decision of which service gets the new case until early the day before surgery reduces overutilized OR time by <15 min per OR per day as compared to releasing the allocated OR time 5 days before surgery. These results show that when OR time is released has a negligible effect on OR efficiency. This is especially true for ambulatory surgery centers with brief cases or large surgical suites with specialty-specific OR teams. What matters much more is having the correct OR allocations and, if OR time needs to be released, making that decision based on the scheduled workload. ⋯ Provided operating room (OR) time is allocated and cases are scheduled based on maximizing OR efficiency, then whether OR time is released five days or one day before the day of surgery has a negligible effect on OR efficiency.
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Anesthesia and analgesia · Mar 2004
Clinical TrialAnalgesia after total knee arthroplasty: is continuous sciatic blockade needed in addition to continuous femoral blockade?
Continuous femoral "3-in-1" nerve blocks are commonly used for analgesia after total knee arthroplasty (TKA). There are conflicting data as to whether additional sciatic blockade is needed. Our routine use of both continuous femoral (CFI) and sciatic (CSI) peripheral nerve blocks was changed because of concerns that sciatic blockade, and its motor consequences in particular, might obscure diagnosis of perioperative sciatic nerve injury. ⋯ Within 1 h of a 5-10 mL CSI bolus of 0.2% ropivacaine and beginning an infusion of the same drug at 5 mL/h, patients' median pain by verbal analog scale decreased from 7.5 to 2.0 (mean scores from 7.3 to 2.4). It was possible to maintain this level of analgesia until the third postoperative day when catheters were discontinued. Our experience suggests that, in most patients, adequate analgesia after TKA cannot be achieved with CFI alone and that the addition of CSI renders a significant improvement in analgesia.
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Anesthesia and analgesia · Mar 2004
Attenuation of gap-junction-mediated signaling facilitated anesthetic effect of sevoflurane in the central nervous system of rats.
Accumulating evidence suggests that reduction of intrinsic excitability or synaptic excitation and/or an enhancement of synaptic inhibition underlie the general anesthetic condition. Besides chemical synapse, neurons could communicate with each other by electrical coupling via gap-junctions. We hypothesized that inhibition of cell-to-cell signaling through gap-junction in the central nervous system (CNS) is involved in the anesthetic mechanism of volatile anesthetics. The minimum alveolar concentration (MAC) of sevoflurane was measured after the intracerebroventricular (ICV) or intrathecal (IT) administration of carbenoxolone (CBX), a gap-junction inhibitor, in vivo. The spontaneous oscillation in membrane currents of locus coeruleus neurons that results from electrical coupling between neurons was also recorded from young rat pontine slices by the patch clamp method, and the effect of sevoflurane on this oscillation was examined in vitro. The ICV administration of CBX (125 and 250 micro g/rat) significantly reduced the MAC of sevoflurane dose-dependently, whereas IT injection failed to inhibit the MAC. Sevoflurane at clinically relevant concentrations (0.1-0.5 mM) suppressed the spontaneous oscillation in membrane current concentration-dependently. These suppressions were significant at 0.5 mM with both amplitude and frequency. We suggest that suppression of gap-junction-mediated signaling in the CNS is involved in the anesthetic-induced immobilization by sevoflurane. ⋯ The intracerebroventricular administration of the gap-junction inhibitor, carbenoxolone, reduced the MAC of sevoflurane, and sevoflurane suppressed the signaling through gap-junctions in the central nervous system. The inhibition of gap-junctions may be one of the mechanisms and the site of action of sevoflurane.