Comparison of 0.25 mg and 0.1 mg intrathecal morphine for analgesia after
Cesarean section. Can. J. Anaesth.1999;
46 (9) 856-.60. Yang T, Breen TW, Archer D, Fick G. Department of Anesthesia,
Foothills Hospital, The University of Calgary, Alberta,Canada. email@example.com
PURPOSE: To test the hypothesis that 0.1 mg intrathecal morphine plus NSAIDs provides satisfactory analgesia post-Cesarean section with fewer side effects than 0.25mg intrathecal morphine.
METHODS: Sixty women, scheduled for elective Cesarean section under spinal anesthesia, were randomized to
receive either 0.1mg or 0.25 mg intrathecal morphine combined with hyperbaric bupivacaine 0.75% and 20 microg fentanyl. All patients received a 100 mg indomethacin suppository at the end of surgery and 500 mg naproxen p.o. b.i.d. was started the evening of surgery and continued until discharge. A blinded researcher recorded the pain, pruritus, and nausea scores, the time to first request for additional analgesics, a visual analogue scale (VAS) satisfaction score, and the use of additional opioids, antipruritics, and/or antiemetics.
RESULTS: Of the 60 patients enrolled, two were not included in the data analysis because of protocol violations leaving 30 patients in the 0.1 mg group and 28 in the 0.25 mg group. There were no differences in the VAS pain
scores or the number of women requesting an opioid other than codeine between the two groups. The VAS pruritus scores in the 0.1 mg group were lower throughout the 24 hr (P<0.001). Fewer women in the 0.1 mg group (4/30 vs 12/28) requested nalbuphine to treat itching (P =>0.018). Nausea scores were lower in the 0.1 mg group (P < 0.001).
CONCLUSION: The use of 0.1 mg intrathecal morphine plus NSAIDs provides analgesia of similar quality to 0.25 mg but with fewer undesirable side effects following Cesarean section [citas]
Spinal anesthesia for lumbar disc surgery review of 576 operations.
DJ, Dunsmore RH, Dickson CM. Anesth Analg. 1976 Jul-Aug; 55 (4) 550-4.
Neurologic complications accompanying spinal anesthesia were examined in 576 lumbar disc operations on 507 patients. The single serious complication did not seem attributable to the choice of anesthetic method. Minor neurologic complications, with the exception of spinal headache, could be explained by surgical manipulation. The authors conclude that spinal anesthesia is safe for surgical operations on the laterally herniated lumbar disc [citas]
The epidural structure changes during deep breathing.
T, Hirabayashi Y, Shimizu R, Saitoh K, Fukuda H. Can. J. Anesth.
1999 Sep; 46 (9):850-55. Department of Anesthesiology, Jichi Medical School,
Kawachi-gun, Tochigi-ken, Japan.
PURPOSE: Previous experience has suggested that the insertion of an epidural catheter becomes easier when the patient takes a deep breath. The purpose of this study is to investigate the effects of respiration on the epidural space.
METHODS: We examined the epidural space using a flexible epiduroscope in 20 patients undergoing thoracic epidural anesthesia. A 17-gauge Tuohy needle was inserted using the paramedian technique and the loss-of-resistance method with 5 ml air. The epiduroscope was introduced into the epidural space via the Tuohy needle. Each patient was requested to take a deep breath when the epiduroscope was positioned at the needle tip and at approximately 10 cm cephalad from the needle tip within the epidural space. The changes in the epidural structure during deep breathing at each site were then measured.
RESULTS: In 80% of the patients, fatty tissue occupied the needle tip. Through the patients' maximal inspiration, the fatty tissue moved and a visible cavity expanded at the needle tip. Cross section area of the visible cavity at the needle tip was greater at the maximal inspiratory level than at the resting expiratory level: 12.1+/- 6.7% vs 2.8 +/- 2.1% (mean +/- SD, P < 0.0001). In all patients, the visible cavity within the epidural space, which had already been expanded by injected air, became more expanded after maximal inspiration. Cross section area of the visible cavity at the 10 cm cephalad position was greater at the maximal inspiratory level than at the resting expiratory level: 20.6 +/- 10.0% vs 7.0 +/- 5.3% (P < 0.0001).
CONCLUSION: Epiduroscopy showed that deep breathing expanded the potential cavity of the epidural space. We suggest that the changes in the epidural structure during deep breathing may assist in the insertion of an epidural catheter [citas]
Thoracic epidural analgesia versus intravenous patient-controlled analgesia
for the treatment of rib fracture after motor vehicle crash.
J. Trauma. 1999 Sep; 47 (3) : 564-7. Department of Anesthesia, University
of Rochester School of Medicine and Dentistry,New York, USA. Wu CL, Jani
ND, Perkins FM, Barquist E.
BACKGROUND: Pain from rib fracture pain may affect pulmonary function, morbidity, and length of intensive care unit stay. Previous trials have varied epidural technique within the study and have used several outcome variables.
METHODS: The charts of patients who sustained rib fractures after a motor vehicle crash between January 1,1994, and June 30, 1997, were reviewed. Data were collected from 64 patients who had three or more rib fractures and initiation of intravenous patient-controlled analgesia with morphine or thoracic epidural analgesia with bupivacaine and fentanyl within 24hours of admission.
RESULTS: Injury Severity Score and Acute Physiology and Chronic Health Evaluation II scores were not significantly different between groups. Patients in the epidural group had significantly more rib fractures and were
significantly older. Patients who received epidural analgesia had significantly lower pain scores at all times. There were no differences in the lengths of intensive care unit or hospital stays, or the incidence of npulmonary complications or organ failure between groups.
CONCLUSION: Thoracic epidural analgesia with bupivacaine and fentanyl provided superior analgesia than intravenous patient-controlled analgesia morphine [citas]
A comparison of the antibacterial activity of levo-bupivacaine versus bupivacaine:
an in vitro study with bacteria implicated in epidural infection.Hodson
M, Gajraj R, Scott NB. Anesthesia 1999 Jul; 54 (7): 699-702. Department
of Anaesthesia, Health Care International (Scotland) Ltd, Beardmore Street,
Clydebank, Glasgow G81 4DY, UK.
The purpose of the study was to compare the antibacterial activity of bupivacaine with levo-bupivacaine against a range of bacteria implicated in epidural infection to determine whether any differences existed between the two drugs. Concentrations of 0.125%, 0.25% and 0.5% bupivacaine and levo-bupivacaine were inoculated with suspensions of either Staphylococcus epidermidis, Staphylococcus aureus or Enterococcus faecalis. After incubation, the mixtures were plated onto blood agar and colony counts were recorded after a further period of incubation. The minimum bactericidal concentration of local anaesthetic against the three bacteria studied was found to be 0.25% for bupivacaine and 0.5% for levo-bupivacaine showing racemic bupivacaine to have a more potent antibacterial action than levo-bupivacaine. This finding suggests that the dextrobupivacaine isomer of racemic bupivacaine has a more potent antibacterial action than the levo-bupivacaine isomer [citas]
Síndrome de la arteria espinal anterior.
Devesa A, Saez-Pérez JM, Sánchez-Roy R, Torres-García
J, Simo C. Rev Neurol. 1999 May ; 28 (9): 878-80, Hospital Arnau de Vilanova,
INTRODUCTION: Ischemic spinal cord infarct is the most frequent vascular lesion, but although aortic aneurysms are a possible cause, it is unusual for such cases to be seen. Clinical case. We present a case of spinal ischemia as the first sign of the dissection of an aneurysm of the abdominal aorta. A 58 year old man was seen
in the hospital Emergency Department complaining of lumbar pain and the sudden onset of paraplegia of the legs, associated with pain in the middle of his back but with no history of previous trauma or effort. The only
relevant personal history was of smoking. Whilst he was in the Neurology Department, the anomaly was diagnosed after dorsal, and lumbar gadolinium magnetic resonance (MR), when a zone of ischaemia at T9-T10 was seen and, as a casual observation, an image compatible with an aneurysm of the abdominal aorta. The relationship between the dissection of the aorta and the neurological complications may be explained by a clear understanding of the vascular supply to the spinal cord. In this case, both the clinical findings and the MR were clearly indicative of an anterior spinal artery syndrome.
CONCLUSIONS: In spite of its rarity, aortic aneurysm should be included in the differential diagnosis of a clinical picture of ischemic myelopathy, especially when here is lumbar and/or abdominal pain before the appearance
of neurological symptoms. Spinal MR is important for thisdiagnosis [citas]
Serial MRI study on a case of anterior spinal sydrome.
Ono K, Takizawa Y, Komai K, Takamori M. Rinsho Shinkeigaku 1998 Sep; 38
(9): 806-10. Department of Neurology, Kanazawa University School of Medicine.
A 63-year-old woman suddenly began to suffer from left chest pain. She gradually became unable to walk and was admitted to the emergency room at another hospital. When she became paraplegic in spite of steroid therapy, she was admitted to our hospital. Her affliction was diagnosed as anterior spinal artery syndrome because of flaccid paraplegia and dissociated sensory loss below the Th4 dermatome.Hematological study indicated a compensated DIC and hepatic enzyme abnormality, while the CSF examinations showed an elevation of protein and positive myelin basic protein (MBP) elevation. The initial MRI taken in the acute stage showed no abnormal signals on T1-weighted (T1) and Gd-enhanced images. The sagittal T2-weighted image(T2) revealed central high intensity (HI) with longitudinal extension from Th2 through the Th11 vertebral level. On axial T2, HI was located on the gray matter at the Th3 and Th4 vertebral level, the ventral two-thirds at the Th8 vertebral level,the central ventral side at the Th9 and Th10 vertebral level, and the entire cross section at the Th12 and L1. A follow-up MRI examination showed that the range of HI on the sagittal T2 had been reduced to 5 segments from Th6 through Th10 vertebral level. The T2 HI lesion on the axial aspect had become reduced so as to localize on the left ventral side at the Th8 vertebral level and on the central ventral side at Th9 and Th10[citas]
Anterior spinal artery syndrome associated with severe stenosis of the
vertebral artery. Suzuki K, Meguro K, Wada M,
Nakai K, Nose T. Am J Neuroradiol 1998 Aug; 19 (7): 1353-55. Department
of Neurosurgery, Tsukuba Medical Center Hospital, Ibaraki, Japan.
We describe a 55-year-old man with quadriparesis and impaired pain and temperature sensation in whom T2-weighted MR images revealed a high-intensity lesion in the cord at C3-4. Angiography showed occlusion of the right vertebral artery and severe stenosis of the left vertebral artery. We concluded that the stenosis of the vertebral artery led to the anterior spinal artery syndrome and to a disturbance of consciousness [citas]
Anterior spinal artery syndrome after thoraco-abdominal esophagus resection.A
rare complication. Boedeker H, Schmidt J, Zirngibl H. Chirurg 1997,
Sep; 68 (9): 902-5. Klinik und Poliklinik fur Chirurgie, Universitat Regensburg.
We report a case of postoperative paraplegia resembling an anterior spinal artery syndrome after curative esophagectomy in a patient with carcinoma of esophagus and clinical stage III (UICC). Neurologic deficit was
characterized by loss of sensibility at the level of T12/L1 together with paraparesis of both lower extremities. Furthermore, dissociated sensorimotor depletion at C6/C7 (right-sided) and at T5(left-sided) was noted. This
severe complication was most probably caused by peeling of an arteriosclerotic plaque of the thoracic aorta due to preexisting advanced arteriosclerosis, leading to a partial occlusion of the great radicular artery of Adamkiewicz. Even though anterior spinal artery syndrome is a well-known problemin the operative management of thoracic aortic aneurysms, this complication has no previously been reported after esophagectomy [citas]
Spinal artery syndrome masked by postoperative apidural analgesia.Linz
SM, Charbonnet C, Mikhail MS, Vadehra N, Zelman V, Katz RL,Thangathurai
D. Can J Anaesth. 1997 Nov; 44 (11): 1178-81. Department of Anesthesiology,
University of Southern California School of Medicine, Los Angeles, USA.
PURPOSE: We report a case of a patient who developed a postoperative anterior spinal artery syndrome that was masked by the use of epidural analgesia. We wish to alert other anaesthetists that the use of epidural anaesthesia in this setting may mask the symptoms and delay the diagnosis of this rare complication.
CLINICAL FEATURES: The patient was a 22-yr-old obese man with metastatic testicular carcinoma who underwent a left-sided thoracoabdominal retroperitoneal tumour resection. A lumbar epidural catheter was placed preoperatively for pain management. Postoperatively, the patient developed bilateral lower extremity weakness, which was at first attributed to epidural administration of local anaesthetics. Despite discontinuation of the local anaesthetics, the symptoms persisted. Further work-up led to the diagnosis of anterior spinal artery syndrome. The patient was sent to a rehabilitation hospital and had a partial recovery.
CONCLUSION: Anterior spinal artery syndrome can occur following retroperitoneal surgery. It is important to recognize the potential for this complication when postoperative epidural analgesia is contemplated, especially following a left-sided surgical dissection. The use of epidural local anaesthetics immediately after surgery delays the diagnosis of a postoperative neurological deficit. Moreover, when the deficit is recognized the epidural itself may be falsely blamed for postoperative paraplegia. If epidural analgesia is used, opioids may be preferred over local anaesthetics in the immediate postoperative period to prevent masking of an anterior spinal artery syndrome[citas]
A case of spinal myoclonus associated with epidural block for lumbago.Ogata
K, Yamada T, Yoshimura T, Taniwaki T, Kira J. Rinsho Shinkeigaku.1999
Jun; 39( 6) :658-60. Department of Neurology, Faculty of Medicine, Kyushu
University, Fukuoka (Article in Japanese).
We herein report a case of spinal myoclonus following the administration of epidural anesthesia. A 25-year-old woman underwent lumbar epidural anesthesia because of lumbago and cramps in her left lower limb. She immediately felt a lancinating pain in her left limb during anesthesia at the level of L 4/5 and soon developed myoclonus in her left thigh. The neurological examination revealed rhythmic myoclonus in the left quadriceps and adductor thigh muscles. The myoclonus disappeared after performing a blockade of the left L 4 spinal root by using 1.5 ml of 1% lidocaine. An injury to the left L 4 nerve root during the epidural anesthesia possibly caused an abnormal transmission of the impulses or ectopic hyperexcitability in the nerve root, which might lead to the disturbance of the spinal inhibitory interneurons and hyperexcitability of the anterior horn cells causing myoclonus. Since she did not demonstrate any muscular weakness, nor sensory loss during the lidocaine block, the 1% lidocaine appeared to block the sympathetic nerves or to suppress the ectopic hyperexcitability. The sympathetic nerves may be involved in the development of her spinal myoclonus [citas]
Disappearance of wheezing during epidural lidocaine anesthesia in a patient
with bronchial asthma. Shono S, Higa K, Harasawa
I, Sugano H, Dan K. Reg Anesth Pain Med.1999 Sept-Oct; 24 (5). 463-66.
Department of Anesthesiology, School of Medicine, Fukuoka University, Japan.
BACKGROUND AND OBJECTIVES: Local anesthetics in blood absorbed from the epidural space attenuate bronchial hyperreactivity to chemical stimuli. However, it is not documented whether local anesthetics at clinically relevant concentrations improve active wheezing in patients with bronchial asthma.
CASE REPORT: We managed a 60-year-old man with bronchial asthma and active wheezing under continuous epidural anesthesia using plain lidocaine. The wheezing gradually diminished 20 minutes after the epidural injection of 13 mL 2% lidocaine and completely disappeared over 155 minutes during continuous epidural injection of 2% lidocaine (6 mL/h). The plasma concentrations of lidocaine in arterial blood during the epidural anesthesia ranged from 2.5 to 3.9 microg/mL. Wheezing reappeared 55 minutes after termination of thecontinuous epidural injection of lidocaine. The plasma concentration of lidocaine at this time was 1.9 microg/mL.
CONCLUSIONS: At clinically relevant concentrations, lidocaine in the blood absorbed from the epidural space may improve bronchospasm in patients with bronchial asthma [citas]
Neurological deficit following spinal anaesthesia: MRI and CT evidence
of spinal cord gas embolism. Tedeschi E, Marano
I, Savarese F, Olibet G, Di Salvo E, Brunetti A, Sodano A. Neuroradiology
1999 Apr;41(4):275-8. Department of Biomorphological and Functional Sciences,
CNR Center for Nuclear Medicine, University Frederico II, Naples, Italy.
A 62-year-old diabetic woman developed permanent neurological deficits in the legs following spinal anaesthesia. MRI showed oedema in the spinal cord and a small intramedullary focus of signal void at the T10 level, with negative density at CT. Intramedullary gas bubbles have not been reported previously among the possible neurological complications of spinal anaesthesia; a combined ischaemic/embolic mechanism is hypothesised [citas]
Thoracic epidural anesthesia reduces infarct size in a canine model of
myocardial ischemia and reperfusion injury. Groban
L, Zvara DA, Deal DD, Vernon JC, Carpenter RL. J Cardiothorac Vasc Anesth
1999 Oct;13(5):579-85. Department of Anesthesiology, Wake Forest University
School of Medicine, Winston-Salem, NC 27157-1009, USA. firstname.lastname@example.org
OBJECTIVE:To determine the effects of thoracic epidural anesthesia on myocardial infarct size, regional myocardial blood flow (RMBF), and plasma norepinephrine in an anesthetized canine model of ischemia reperfusion injury with infarction.
DESIGN:Blinded, randomized, placebo-controlled animal study.
SETTING: Experiments were performed in the cardiothoracic research laboratory at Wake Forest University Baptist Medical Center.
PARTICIPANTS: Anesthetized, open-chest mongrel dogs were used in these studies.
METHODS: Dogs were instrumented for measurement of aortic pressure (AP) and left ventricular systolic pressure (LVSP), dP/dt, and RMBF Epidural catheters were inserted at thoracic segment T5. Three groups received epidural 0.5% bupivacaine: low-dose (n = 7; 0.3 mg/kg bolus, 0.15 mg/kg/ h), mid-dose (n = 7; 0.6 mg/kg bolus, 0.3 mg/kg/h), high-dose (n = 7; 1.2 mg/kg bolus, 0.6 mg/kg/h). The vehicle (VEH) group received epidural saline. Bolus followed by maintenance infusions began 30 minutes before the onset of ischemia (60 min) and continued through reperfusion (180 min).
RESULTS: Myocardial infarct size was significantly reduced in the high-dose group versus the VEH and
low-dose groups (p < 0.05). After initiation of the mid and high dose, AP, LVSP, and dP/dt decreased 7% to 16% (high vVEH; p < 0.05). VEH dogs showed a 130% increase from control in early postischemic RMBF. There was a dose-dependent attenuation in this reflow response: 72%, 31%, and 6% increase in RMBF in the low, mid, and high groups, relative to controls (p < 0.05 high v VEH). Although there was no significant difference in plasma norepinephrine, fewer surges occurred in the high-dose group.
CONCLUSIONS: Thoracic epidural anesthesia reduces infarct size and postischemic hyperemia in a model of ischemia reperfusion injury [citas]
Addition of intrathecal midazolam to bupivacaine produces better post-operative
analgesia without prolonging recovery. Batra
YK, Jain K, Chari P, Dhillon MS, Shaheen B, Reddy GM. Int J Clin Pharmacol
Ther 1999 Oct;37(10):519-23. Department of Anaesthesiology, Postgraduate
Institute of Medical Education and Research, Chandigarh, India.
OBJECTIVE:The administration of midazolam by centroneuraxis route has been shown to produce segmental antinociception. This midazolam analgesia was found to enhance the effects of local anesthetics given in combination epidurally without any adverse effects. The present study was designed to evaluate the post-operative analgesic effect of intrathecal midazolam-bupivacaine mixture in patients undergoing knee arthroscopy.
METHODS:Thirty healthy patients scheduled for knee arthroscopy were divided into two groups to receive either midazolam-bupivacaine mixture (group M; n =15) or bupivacaine alone (group B; n = 15) intrathecally. Level of sensory block, sedation score, assessment of pain using visual analogue score were recorded in both groups at regular time intervals. Time to block regression, recovery to ambulation and ability to void were recorded and noted before discharge.
RESULTS:A significantly higher VAS score was seen in group B patients as compared to the score observed in group M patients before discharge (p<0.05). All patients received rescue analgesia in group B at a mean duration of 258 +/-46.8 minutes whereas only one patient in group M required supplemental analgesia within this period. Time to regression of sensory analgesia to L5-S1 level was longer in group M (267+/-67.38) as compared to group B (229.8+/-41.4) (p<0.05). Blood pressure, heart rate, oxygen saturation and sedation score showed no differences between the groups. Neither motor block nor time to void were prolonged with the addition of midazolam to bupivacaine.
CONCLUSION:The results suggest that addition of midazolam to bupivacaine intrathecally provided better post-operative analgesia without any adverse effect [citas]
A comparison of simple tests to distinguish cerebrospinal fluids from saline.Walker
DS, Brock-Utne JG. Can. J. Anaesth 1997 May; 44 : 494-7. Department of
Anesthesia, Stanford University Medical Center, CA 94305-5115, USA.
PURPOSE: This prospective study was undertaken to determine if anesthesiologists of different levels of training, using simple tests, can distinguish cerebrospinal fluid (CSF) from saline.
METHODS: Thirty-two anaesthetists, divided into four groups, dependent upon levels of training, participated in the study. Each was asked to distinguish saline from an artificial CSF solution using four different tests: tactile
temperature, glucose strip, pH strip, and turbidity when mixed with thiopental.
RESULTS: Participants identified cerebrospinal fluid correctly with 84% accuracy using the temperature test, 97% using the glucose test, 91% using the pH test, and 50% using the thiopentone test. More than half o the participants guessed while using the thiopentone test, and those who did not guess were only 47%accurate.
CONCLUSION: Level of training made no difference in distinguishing CSF from saline. No one test was 100% reliable. Clinical utility of the thiopentone test appears to be limited. The temperature, glucose, and pH tests, when used together, appear to be a useful way of distinguishing CSF from saline [citas]
peripheral nerve block resulting in compartment syndrome.
Case report. Am J Phys Med Rehabil 1988 Apr;67(2):82-4. Parziale JR, Marino
AR, Herndon JH. Dept. of Orthopaedics and Rehabilitation, Rhode Island
Hospital, Providence 02903.
A hemiplegic patient with severe upper extremity spasticity 2 years after a cerebrovascular accident received a diagnostic median nerve block below the elbow with bupivacaine. He had been placed on Coumadin as prophylaxis for cerebrovascular arteriosclerotic disease, and prothrombin time was kept at twice the control value. Less than 48 hours after the procedure, a compartment syndrome developed in the volar forearm. Compartment syndrome has not previously been reported as a complication resulting from a nerve block procedure. We conclude that (1) compartment syndrome may develop after a peripheral nerve block procedure for spasticity, (2) prophylactic anticoagulation may increase the risk for hemorrhagic events resulting from percutaneous injection and (3) early
recognition is essential and appropriate decompressive fasciotomy may be indicated if a compartment syndrome develops after a nerve block procedure [citas]
midazolam to bupivacaine produces better post-operative analgesia without
prolonging recovery. Int J Clin Pharmacol
Ther 1999 Oct;37(10):519-23. Batra YK. JainK Chari P. Dhillon MS, Shaheen
B, Reddy GM. Addition of Department of Anaesthesiology, Postgraduate Institute
of Medical Education and Research, Chandigarh, India.
OBJECTIVE: The administration of midazolam by centroneuraxis route has been shown to produce segmental antinociception. This midazolam analgesia was found to enhance the effects of local anesthetics given in combination epidurally without any adverse effects. The present study was designed to evaluate the post-operative analgesic effect of intrathecal midazolam-bupivacaine mixture in patients undergoing knee arthroscopy.
METHODS: Thirty healthy patients scheduled for knee arthroscopy were divided into two groups to receive either midazolam-bupivacaine mixture (group M; n=15) or bupivacaine alone (group B; n=15) intrathecally. Level of sensory
block, sedation score, assessment of pain using visual analogue score were recorded in both groups at regular time intervals. Time to block regression, recovery to ambulation and ability to void were recorded and noted beforedischarge.
RESULTS: A significantly higher VAS score was seen in group B patients as compared to the score observed in group M patients before discharge (p<0.05). All patients received rescue analgesia in group B at a mean duration of 258 +/-46.8 minutes whereas only one patient in group M required supplemental analgesia within this period. Time to regression of sensory analgesia to L5-S1 level was longer in group M (267+/-67.38) as compared to group B (229.8+/-41.4) (p<0.05). Blood pressure, heart rate, oxygen saturation and sedation score showed no differences between the groups. Neither motor block nor time to void were prolonged with the addition of midazolam to bupivacaine.
CONCLUSION: The results suggest that addition of midazolam to bupivacaine intrathecally provided better post-operative analgesia without any adverse effects [citas]
of local anesthetics - an issue or a scapegoat?. Moore
DC, Thompson GE.Commentary: Reg Anesth Pain Med. 1998 Nov-Dec; 23
(6):605-10. Department of Anesthesiology, Virginia Mason Medical Center,
Seattle, Washington 98111-0900, USA.
BACKGROUND AND OBJECTIVES:To evaluate the etiologies of cauda equina syndrome (CES) and transient radicular irritation (TRI) or transient neurologic symptoms (TNSs) following hyperbaric spinal anesthesia.
METHODS:A review of recent (since 1991) and prior (since 1941) investigations regarding CES and TRI (TNSs) was conducted.
RESULTS:Recent publications fail to recognize significant prior information regarding CES and TRI (TNSs).
CONCLUSIONS: Cauda equina syndrome is, in all probability, explainable. Further investigation to pinpoint the etiology of TRI (TNSs) is neede [citas]
equina syndrome after spinal anaesthesia with hyperbaric 5% lignocaine:
a review of six cases of cauda equina syndrome reported to the Swedish
Pharmaceutical Insurance 1993-1997.Loo
CC, Irestedt L. Acta Anaesthesiol Scand 1999 Apr;43(4): 371-9. Dept.
of Anaesthesia, KK Women's & Children's Hospital, Republic of Singapore.
Six cases of cauda equina syndrome with varying severity were reported to the Swedish Pharmaceutical
Insurance during the period 1993-1997. All were associated with spinal anaesthesia using hyperbaric 5% lignocaine. Five cases had single-shot spinal anaesthesia and one had a repeat spinal anaesthetic due to inadequate block. The dose of hyperbaric 5% lignocaine administered ranged from 60 to 120 mg. Three of the cases were most likely caused by direct neurotoxicity of hyperbaric 5% lignocaine. In the other 3 cases, direct neurotoxicity was also probable, but unfortunately radiological investigations were not done to definitely exclude a compressive aetiology. All cases sustained permanent neurological deficits. We recommend that hyperbaric lignocaine should be administered in concentrations not greater than 2% and at a total dose preferably not exceeding 60 mg. Comment in: Acta Anaesthesiol Scand 1999 Apr;43(4):369-70
of outcome in cauda equina syndrome.Eur
Spine J. 1998;8 (4): 317-22. Kennedy JG, Soffe KE, McGrath A, Stephens
MM, Walsh MG, McManus F. Department of Orthopaedic Surgery, University
College Dublin, Mater Misericordiae Hospital, Ireland.
This retrospective review examined the cause, level of pathology, onset of symptoms, time taken to treatment, and outcome of 19 patients with cauda equina syndrome (CES). The minimum time to follow up was 22 months. Logistical regression analysis was used to determine how these factors influenced the eventual outcome. Out of 19 patients, 14 had satisfactory recovery at 2 years post-decompression; 5 patients were left with some residual dysfunction. The mean time to decompression in the group with a satisfactory outcome was 14 h (range 6-24 h) whilst that of the group with the poor outcome was 30 h(range 20-72 h). There was a clear correlation between delayed decompression and a poor outcome (P =0.023). Saddle hypoaesthesia was evident in all patients. In addition complete perineal anaesthesia was evident in 7/19 patients, 5 of whom developed a poor outcome. Bladder dysfunction was observed in 19/19 patients, with 12/19 regarded as having significant impairment. Of the five patients identified as having a poor overall outcome, all five presented with a significant sphincter disturbance and 4/5 wereleft with residual sphincter dysfunction. There was a clear correlation between the presence of complete perineal
anaesthesia and significant sphincter dysfunction as both univariate and multivariate predictors of a poor overall outcome. The association between a slower onset of CES and a more faourable outcome did not reach statistical significance (P = 0.052). No correlation could be found between initial motor function loss, bilateral sciatica, level
or cause of injury as predictors of a poor outcome (P>0.05). CES can be diagnosed early by judicious physical examination, with particular attention to perineal sensation and a history of urinary dysfunction. The most important factors identified in this series as predictors of a favourable outcome in CES were early diagnosis and early
disorders of micturition and their treatment. Fowler
CJ. Brain 1999 Jul; 122 (Pt7):1212-31. Department of Uro-Neurology, National
Hospital for Neurology and Neurosurgery, Institute of Neurology and Institute
of Urology, UCL, London, UK.
An overview of the current concepts of the neurological control of the bladder is given, based on laboratory experiments and PET scanning studies in human subjects. This is followed by a description of the various causes of the neurogenic bladder, discussed in a hierarchical order starting with cortical lesions and descending through the basal ganglia and brainstem, spinal cord, conus and cauda equina to disorders of peripheral innervation. Then follows a description of the condition of isolated urinary retention in young women. The article concludes with a review of the methods available for treating neurogenic bladder disorders. These are largely medical but brief mention of appropriate surgical procedures is made [citas]
alfuzosin and trial without catether after acute urinary retention. A prospective,
placebo-controlled.McNeill SA, Daruwala
PD, Mitchell ID, Shearer MG, Hargreave TB. BJU Int.1999 Oct;84(6): 622-627
.Western General Hospital, Edinburgh.
OBJECTIVE:To establish whether the administration of sustained-release (SR) alfuzosin improves the outcome of a trial without catheter (TWOC) after an episode of acute urinary retention.
PATIENTS AND METHODS:In a prospective, randomized, placebo-controlled trial, 81 patients with acute urinary retention related to benign prostatic obstruction received either SR alfuzosin (n=40), an alpha1-selective blocker, given at a dose of 5 mg twice daily, or placebo (n=41) for 48 h. The catheter was removed after 24h of treatment. The main outcome measurement was success or failure of the TWOC. At the end of this double-blind phase the patients were followed up on an open basis.
RESULTS:After removal of the catheter, 42% of patients voided successfully, 22 of 40 (55%) with SR alfuzosin and 12 of 41 (29%) with placebo (P=0.03). The mean age of patients voiding successfully, regardless of treatment group, was 68.4 years, whilst the mean age of those who were not successful was 72.9 years (P=0.015). In an intention-to-treat analysis of outcome adjusted for this age difference, the benefit in favour of those receiving SR
alfuzosin was not significant, but at P=0.052 there was a strong suggestion of a positive treatment effect. The observed benefit remained significant in a per-protocol analysis adjusted for age. Taken together, these results indicate that treatment with SR alfuzosin was effective and that the observed benefit was not simply the effect of age difference between the groups. Of the 34 patients who voided successfully 23 (68%) required no further intervention within a mean follow-up of 7 months.
CONCLUSIONS:Treatment with SR alfuzosin is effective in improving the success rate of a TWOC after an episode of acute urinary retention, although older patients are less likely to void successfully. By reducing the numbers of men sent home with urinary catheters, such treatment may result in a reduction in the associated perioperative morbidity in those undergoing prostatic surgery, and is clearly desirable for the patients' comfort and convenience [citas]
volume and local anesthetic concentratin modify the spread of epidural
anesthesia.Okutomi T, Minakawa M, Hoka
S. Can J Anaestha 1999 Oct;46(10): 930-4. Department of Anesthesiology,
Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan.
PURPOSE: To examine the effects of the volume of saline and the concentration of local anesthetic on the quality of anesthetic level.
METHODS: One hundred and fifty two patients received thoracic epidural anesthesia were allocated into two groups; mepivacaine 1% (75 patients) and 1.5% (77 patients). Each group was randomly divided into three subgroups
depending on epidural saline volumes of 1 ml, 5 ml, or 10 ml. Fifteen minutes after the injection of 10 ml mepivacaine, the dermatome levels of hypesthesia to cold and pinprick were determined by an individual blinded to the saline volume.
RESULTS: The number of spinal segments with hypesthesia to cold in the three subgroups in the mepivacaine 1% group were 12.5 [6-20], 13 [8.5-20.5] and 12.5 [6.5-22], respectively (median[range]). The segments in the mepivacaine 1.5% group were 12 [7-18.5], 14 [8.5-19]* and 15 [6-23*, respectively (*P < 0.05 vs 1-ml group). The number of spinal segments with hyposthesia for pinprick in the thre subgroups in the 1% mepvacaine group were 10.5 [2-22], 10.5 [4-17] and 11 [4-19],respectively. The segments in the mepivacaine 1.5% group were 12 [7.5-16], 12 [7.5-17] and 11.5 [5-22.5],respectively. Saline volume did not alter the anesthetic level of the mepivacaine 1%, although it did affect the anesthetic spread of the mepivacaine 1.5%. In both groups, a differential nerve block was elicited in the 5 ml and 10 ml saline subgroups.
CONCLUSION: When a large volume of saline is administered prior to local anesthetic, more differential blockade and a greater extent of anesthesia may be elicited [citas]
morphine for coronary artery bypass graft procedure and early extubation
revisted.Chaney MA, Nikolov MP, Blakeman
BP, Bakhos M J. cardiothoracic Vasc anesth. 1999 Oct;13(5):575-8. Department
of Anesthesiology, Loyola University Medical Center, Maywood, IL 60153,
OBJECTIVE: To determine the dose of intrathecal (IT) morphine (along with the intraoperative baseline anesthetic) that provides significant analgesia yet does not delay extubation in the immediate postoperative period in patients undergoing cardiac surgery and early extubation.
DESIGN: Prospective, randomized, double-blinded, placebo-controlled clinical study.
SETTING: Single university hospital.
PARTICIPANTS: Forty patients undergoing elective coronary artery bypass graft procedure and early extubation.
INTERVENTIONS: Twenty patients received 10 microg/kg of IT morphine, and 20 patients received IT placebo. Perioperative anesthetic management was standardized and included postoperative patient-controlled morphine
MAIN RESULTS: Of the patients tracheally extubated during the immediate postoperative period, mean time to extubation was similar in patients who received IT morphine (6.8+/-2.8 h) or IT placebo (6.5+/-3.2 h). Four
patients who received IT morphine had extubation substantially delayed because of prolonged ventilatory depression. There was no difference between groups in postoperative patient-controlled morphine analgesia use.
CONCLUSION: Even when used in conjunction with an intraoperative baseline anesthetic that allows early extubation, IT morphine (10 microg/kg) was unable to provide substantial postoperative analgesia. The risks of using IT morphine in patients undergoing cardiac surgery and early extubation may outweigh the potential benefits [citas]
anaesthesia for outpatients. Korttila
K. Regional Anesthesia for outpatientes. Minerva Anesthesiol 1999 Jun;65(6):401-4
Regional anaesthesia is useful in day surgery when properly applied. Most commonly used techniques are IVRA, axillary block, local/infiltration plus monitored anaesthesia care. Spinal anaesthesia is also frequently used in
DS. Depending on the technique used RA may fasten or prolong discharge when compared to general anaesthesia. The use of monitored anaesthesia care as an adjunct to RA increases patient acceptability and satisfaction with
different blocks. In most cases there is less pain after operation if RA was used when compared to GA but control of pain s important at the time when the block wears off. Patient information and cooperation as well as timely discharge of patients home is important for successful RA in DS [citas]
of labor epidural anesthesia for women with severe huypertensive disease.Hogg
B, Hauth JC, Caritis SN, Sibai BM, Lindheimer M, Van Dorsten JP, Klebanoff
M, MacPherson C, Landon M, Paul R, Miodovnik M, Meis PJ, Thurnau GR,Dombrowski
MP, McNellis D, Roberts JM. Am. J Obstet Gynecol 1999 Nov;181(5):1096-1101.
OBJECTIVE: The aim of this study was to determine whether epidural anesthesia during labor increased the frequencies of cesarean delivery, pulmonary edema, and renal failure among women with severe hypertensive disease.Study Design: We performed a secondary retrospective analysis of a subgroup population within a multicenter double-blind trial of low-dose aspirin therapy for women at high risk for development of preeclampsia. Subjects in whom severe hypertensive disease developed were selected. The primary outcomes were the overall frequencies of cesarean delivery among women with severe hypertensive disease who had labor with and without epidural anesthesia. Other maternal and neonatal outcomes were also compared between women who did and did not receive epidural anesthesia.
RESULTS: Among the women with severe hypertensive disease (n = 444) 327 had labor. Among the women with severe disease who had labor there was no difference in either the overall cesarean delivery rate (32.1% vs 28.0%; P =0.44) or the rate of cesarean delivery for fetal distress or failure to progress (27.8% vs 22.0%; P =0.26) between women who did and did not receive epidural analgesia. Women with chronic hypertension were more likely to have a cesarean delivery overall if they received epidural anesthesia, but there was otherwise no difference in the frequencies of cesarean delivery for these indications between women with and without epidural anesthesia within each of the high-risk groups. Pulmonary edema was rare and acute renal failure did not develop in any women.
CONCLUSION: Epidural anesthesia use did not increase the frequencies of cesarean delivery, pulmonary edema, and renal failure among women with severe hypertensive disease [citas]
epidural-spinal opiod-free anesthesia and analgesia for hysterectomy.
Callesen T, Schouenborg L, Nielsen D, Guldager
H, Kehlet H. Br J Anaesth 1999 Jun;82(6):8881-5 Department of Anaesthesiology,
Copenhagen University Hospital, H:S Hvidovre Hospital, Denmark.
Postoperative nausea and vomiting (PONV) are major problems after gynaecological surgery. We studied 40 patients undergoing total abdominal hysterectomy, allocated randomly to receive opioid-free epidural-spinal anaesthesia or general anaesthesia with continuous epidural bupivacaine 15 mg h-1 or continuous bupivacaine 10 mg h-1 with epidural morphine 0.2 mg h-1, respectively, for postoperative analgesia. Nausea, vomiting, pain and bowel function were scored on 4-point scales for 3 days. Patients undergoing general anaesthesia had significantly higher nausea and vomiting scores (P<0.01) but significantly lower pain scores during rest (P<0.05) and mobilization (P< 0.01). More patients undergoing general anaesthesia received antiemetics (13 vs five; P<0.05), but fewer received supplementary opioids on the ward (eight vs 16; P< 0.05). We conclude that opioid-free epidural-spinal anaesthesia for hysterectomy caused less PONV, but with less effective analgesia compared with general anaesthesia with postoperative continuous epidural morphine and bupivacaine [citas]
nausea and vomiting (PONV) are major problems after gynaecological surgery.
We studied 40 patients undergoing total abdominal hysterectomy, allocated randomly to receive opioid-free
epidural-spinal anaesthesia or general anaesthesia with continuous epidural bupivacaine 15 mg h-1 or continuous bupivacaine 10 mg h-1 with epidural morphine 0.2 mg h-1, respectively, for postoperative analgesia. Nausea, vomiting, pain and bowel function were scored on 4-point scales for 3 days. Patients undergoing general anaesthesia had significantly higher nausea and vomiting scores (P< 0.01) but significantly lower pain scores during rest (P< 0.05) and mobilization (P< 0.01). More patients undergoing general anaesthesia received antiemetics (13 vs five; P< 0.05), but fewer received supplementary opioids on the ward (eight vs 16; P< 0.05). We conclude that opioid-free epidural-spinal anaesthesia for hysterectomy caused less PONV, but with less effective analgesia compared with general anaesthesia with postoperative continuous epidural morphine and bupivacaine [citas]
transfer of fentanyl in early human pregnancy and its detection in fetal
brain.Cooper J, Jauniaux E, Gulbis B,
Quick D, Bromley L. Br J Anaesth 1999 Jun;82 (6):929-31. Academic
Department of Anaesthetics, Middlesex Hospital, London, UK.
We have investigated the transfer of fentanyl across the early human placenta in 38 women (8-14 weeks' gestation) undergoing termination of pregnancy. After administration of a bolus dose of fentanyl 2 micrograms/kg at induction of anaesthesia, maternal blood (n=38), placenta (n=38), amniotic fluid (n=38) and fetal brain (n=7) samples were collected and assayed for fentanyl by radioimmunoassay. Fentanyl was detected in all placental and fetal brain samples but not in amniotic fluid. There was a rapid decrease in fentanyl concentrations in maternal serum after the bolus but placental concentrations had not started to decline 30 min later. There was no difference in placental drug concentrations at different gestational ages. These data suggest that there is rapid transfer of fentanyl to the fetus in early pregnancy and that the drug remains in fetal tissue for some time after the initial dose is given to the mother [citas]
inhibits metabolism of midazolam:competitive inhibition of CYP3A4 in vitro.
Oda Y, Mizutani K, Hase I, Nakamoto T,
Hamaoka N, Asada A Br J Anaesth 1999 Jun;82(6):900-3. Department
of Anesthesiology and Intensive Care Medicine, Osaka City University Medical
Fentanyl decreases clearance of midazolam administered i.v., but the mechanism remains unclear. To elucidate this mechanism, we have investigated the effect of fentanyl on metabolism of midazolam using human hepatic microsomes and recombinant cytochrome P450 isoforms (n=6). Midazolam was metabolized to l'-hydroxymidazolam (l'-OH MDZ) by human hepatic microsomes, with a Michaelis-Menten constant (K(m)) of 5.0 (SD 2.7) mumol litre-1. Fentanyl competitively inhibited metabolism of midazolam in human hepatic microsomes, with an inhibition constant (Ki) of 26.8 (12.4) mumol litre-1. Of the seven representative human hepatic P450 isoforms, CYP1A2, 2A6, 2C9, 2C19, 2D6, 2E1 and 3A4, only CYP3A4 catalysed hydroxylation of midazolam, with a K(m) of 3.6 (0.8) mumol liter-1. Fentanyl competitively inhibited metabolism of midazolam to l'-OH MDZ by CYP3A4, with a Ki of 24.2 (6.8) mumol litre-1, comparable with the Ki obtained in human hepatic microsomes. These findings indicate that fentanyl competitively inhibits metabolism of midazolam by CYP3A4.