Anesthesia and analgesia
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Anesthesia and analgesia · May 2004
Case ReportsGeneral anesthesia for cesarean delivery in a patient with paroxysmal nocturnal hemoglobinuria and thrombocytopenia.
Pregnancy in patients with paroxysmal nocturnal hemoglobinuria (PNH) increases the risk of complement activation, hemolysis, and thrombosis. We describe the anesthetic management of a patient with PNH who underwent general anesthesia for cesarean delivery. Steroids, heparin, and blood products were administered early to minimize the likelihood of a hematologic emergency. ⋯ Pregnancy in patients with paroxysmal nocturnal hemoglobinuria increases the risk of hemolysis, thrombosis, anemia, and thrombocytopenia. We describe the anesthetic management of a patient with paroxysmal nocturnal hemoglobinuria and thrombocytopenia who underwent general anesthesia for cesarean delivery.
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Anesthesia and analgesia · May 2004
Case ReportsTracheal ring fracture during a PercuTwist tracheostomy procedure.
Because of difficult weaning from mechanical ventilation, a 59-yr-old man admitted for emergency cardiac surgery underwent a bedside PercuTwist tracheostomy on day 14 of his intensive care unit stay. We observed a double fracture of the second tracheal ring during the initial dilation process with the PercuTwist dilator, associated with distal migration of a cartilage fragment, which was avulsed from the anterior portion of the second cartilaginous ring. ⋯ Like other antegrade single-step techniques, the PercuTwist tracheostomy presents the risk of anterior tracheal wall damage during the initial stage of the dilation process. Antegrade forces applied to the trachea should be minimized by sufficiently deep skin incision and both slow and smooth initial rotation of the dilator.
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In this study we sought to determine the factors influencing red blood cell (RBC) transfusions and to study the transfusion practice of anesthesiologists during liver transplants. A retrospective study of 206 successive liver transplants was undertaken during a period of 52 mo. Transfused blood products were identified. Twenty variables were analyzed in a univariate fashion. For the multivariate analysis, the cases were divided in 2 subgroups: more than 4 RBC units transfused and 4 or less RBC units transfused. The average number of RBC units transfused during a liver transplant was 2.8 (+/- 3.5) per patient, 32.0% did not receive any RBC, and 19.4% did not receive any blood products during the transplant. Three variables were related to the number of RBC units transfused: the starting International Normalized Ratio value, the starting platelet count, and the duration of surgery. We found that there was a wide difference in the transfusion practice of the anesthesiologists involved in this series of liver transplants. It was difficult to identify predictive factors for RBC transfusions when the transfusion rate was small and because of the variability in human factors. Plasma transfusion did not decrease the rate of RBC transfusions; sometimes it was the contrary. ⋯ This is a retrospective study of 206 liver transplants over 52 mo to identify the predictive factors of red blood cell transfusions and the anesthesiologists' transfusion strategies. We conclude that there is a wide difference in transfusion practices among anesthesiologists.
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Anesthesia and analgesia · May 2004
Randomized Controlled Trial Clinical TrialA prospective, randomized evaluation of the effects of epidural needle rotation on the distribution of epidural block.
We evaluated the effects of turning the tip of the Tuohy needle 45 degrees toward the operative side before threading the epidural catheter (45 degrees -rotation group, n = 24) as compared to a conventional insertion technique with the tip of the Tuohy needle oriented at 90 degrees cephalad (control group, n = 24) on the distribution of 10 mL of 0.75% ropivacaine with 10 microg sufentanil in 48 patients undergoing total hip replacement. The catheter was introduced 3 to 4 cm beyond the tip of the Tuohy needle. A blinded observer recorded sensory and motor blocks on both sides, quality of analgesia, and volumes of local anesthetic used during the first 48 h of patient-controlled epidural analgesia. Readiness to surgery required 21 +/- 6 min in the control group and 17 +/- 7 min in the 45 degree-rotation group (P > 0.50). The maximum sensory level reached on the operative side was T10 (T10-7) in the control group and T9 (T10-6) in the 45 degree-rotation group (P > 0.50); whereas the maximum sensory level reached on the nonoperative side was T10 (T12-9) in the control group and L3 (L5-T12) in the 45 degree-rotation group (P = 0.0005). Complete motor blockade of the operative limb was achieved earlier in the 45 degree-rotation than in the control group, and motor block of the nonoperative side was more intense in patients in the control group. Two-segment regression of sensory level on the surgical side was similar in the two groups, but occurred earlier on the nonoperative side in the 45 degree-rotation group (94 +/- 70 min) than in the control group (178 +/- 40 min) (P = 0.0005). Postoperative analgesia was similar in the 2 groups, but the 45 degree-rotation group consumed less local anesthetic (242 +/- 35 mL) than the control group (297 +/- 60 mL) (P = 0.0005). We conclude that the rotation of the Tuohy introducer needle 45 degrees toward the operative side before threading the epidural catheter provides a preferential distribution of sensory and motor block toward the operative side, reducing the volume of local anesthetic solution required to maintain postoperative analgesia. ⋯ Turning the Tuohy introducer needle 45 degrees toward the operative side before threading the epidural catheter is a simple maneuver that produces a preferential distribution of epidural anesthesia and analgesia toward the operative side, minimizing the volume of local anesthetic required to provide adequate pain relief after total hip arthroplasty.