Canadian journal of anaesthesia = Journal canadien d'anesthésie
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The neuromuscular blocking effects of mivacurium during sevoflurane or halothane anaesthesia was studied in 38 paediatric patients aged 1-12 yr. All received premedication with midazolam, 0.5 mg.kg-1 po and an inhalational induction with up to 3 MAC of either agent in 70% N2O and O2. The ulnar nerve was stimulated at the wrist by a train-of-four stimulus every ten seconds and the force of adduction of the thumb recorded with a Myotrace force transducer. ⋯ All patients showed clinical signs of full recovery of neuromuscular blockade (i.e., headlift, gag, or cough). Pharmacological reversal was not required. It is concluded that following a single intubating dose of mivacurium, the time to maximum relaxation was not different during halothane and sevoflurane anaesthesia; recovery times to 5, 75 and 95% twitch height were longer during sevoflurane anaesthesia and neuromuscular reversal was not necessary.
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Randomized Controlled Trial Clinical Trial
Post-herniorrhaphy pain in outpatients after pre-incision ilioinguinal-hypogastric nerve block during monitored anaesthesia care.
The objective of this study was to evaluate the effect of an ilioinguinal-hypogastric nerve block (IHNB) with bupivacaine 0.25% on the postoperative analgesic requirement and recovery profile in outpatients undergoing inguinal herniorrhaphy with local anaesthetic infiltration. Thirty consenting healthy men undergoing elective unilateral inguinal herniorrhaphy procedures were randomly assigned to receive an IHNB with either saline or bupivacaine according to a double-blind, IRB-approved protocol. All patients received midazolam, 2 mg iv, and fentanyl 25 microgram iv, prior to injection of 30 ml of either bupivacaine 0.25% or saline through the oblique muscle approximately 1.5 cm medial to the anterior superior iliac spine. ⋯ However, the pain visual analogue score at 30 min after entering the PACU was lower in the bupivacaine (versus saline) group (P < 0.05). Although the times to ambulation (86 +/- 18 vs 99 +/- 27 min) and being judged "fit for discharge" (112 +/- 49 vs 126 +/- 30 min) were similar in the two groups, the bupivacaine-treated (vs saline) patients required less oral analgesic medication after discharge (46% vs 85%). We concluded that the use of an ilioinguinal-hypogastric nerve block with bupivacaine 0.25% as an adjuvant during inguinal herniorrhaphy under monitored anaesthesia care decreased pain in the PACU and oral analgesic requirements after discharge from the day-surgery unit.
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Case Reports
Sonoclot coagulation analysis and plasma exchange in a case of meningococcal septicaemia.
On the basis of a patient with fulminant meningococcaemia and severe disseminated intravascular coagulation (DIC) syndrome, the diagnostic potential of a clot impedance test - Sonoclot coagulation analysis - was used to evaluate plasma exchange. A 17-yr-old girl was treated for a fulminant infection with Neisseria meningitidis in our intensive care unit. She developed severe DIC. ⋯ Sonoclot coagulation analyses were normalised several days before routine coagulation analyses. The Sonoclot gave additional information to routine coagulation studies, correctly indicated insufficient haemostasis and predicted a positive outcome. Also, plasma exchanges and platelet transfusions could be controlled in the management of DIC.
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The present study was designed to determine the time-course of recovery of the train-of-four (TOF) ratio during spontaneous recovery from mivacurium-induced block. Fifteen patients, free of neuromuscular disease, undergoing general endotracheal anaesthesia with isoflurane were studied. After anaesthetic induction, patients received a bolus dose of mivacurium 0.15 mg.kg-1. ⋯ The DUR0.3-0.9 averaged 11.8 +/- 3.9 min (range 6.0-20.2 min). There was no evidence of prolongation of recovery times (cumulation) following repeated dosing. The present data indicate that, in patients with normal cholinesterase activity (clinical duration 7-25 min), waiting 20 min beyond the time when fade is no longer apparent by visual or tactile evaluation is sufficient to attain a TOF ratio greater than 0.7-0.9 during spontaneous recovery from mivacurium, and may enable anaesthetists to avoid antagonism of mivacurium-induced block.
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Ebstein's anomaly is an uncommon congenital cardiac defect which is associated with cyanosis and arrhythmias. There have been very few previous reported cases of successful outcome in pregnancy in women with this disorder. We describe the successful analgesic management of an obstetric patient who had been known to have Ebstein's anomaly since childhood. ⋯ Vaginal delivery was managed with elective lift-out forceps to minimize the stress of pushing. When reviewed two months post-partum she still required digoxin although her symptoms had improved considerably. The successful management of Ebstein's anomaly in pregnancy should include team management from early in pregnancy.