A comparison study between newly-designed pencil-point and cutting needles in spinal anesthesia.

OBJECTIVES: The goal of this single blinded randomized study was to compare the use of routine cutting-tip spinal needle and newly-designed pencil-point Pajunk(AE) in terms of success rate, complications and satisfactions in priests undergoing spinal anesthesia for orthopedic, general and urological surgery at Priest Hospital, Thailand. MATERIAL AND METHOD: After Institutional Review Board approval and patients' signed consent, from August 2006 to October 2007, 91 priests were randomly assigned to have 27-gauge Quincke (control group, C) or 25-gauge Pajunk(AE) (study group, S) spinal needles used in their spinal anesthesia. The number of attempts to successful cerebrospinal fluid return and the success rate of the spinal blockade were documented. Postoperatively, an investigator blinded to the study interviewed patients daily. RESULTS: The first-time needling success rate for Quincke was 79% but for Pajunk(AE) only 46%, lower than reported. The incidence of minor complications was small, even there were 2 postoperative dead cases not related to anesthesia. Over 80% of both groups still preferred the same technique and surgeon satisfaction was good to excellent. CONCLUSIONS: The newly-designed, pencil-point spinal needle was another example on the development of more refined towards quality anesthesia. To be cost-effective, it should be selected for patients at risk of CSF leakage-related complications.

Over half MAC sevoflurane in cesarean section.

Half MAC (minimal alveolar concentration) of volatile anesthetics has been commonly used with nitrous oxide for cesarean section which could occur intraoperative awareness. Over half MAC or more than 1% sevoflurane was studied on 65 parturients who came for either elective or emergency operations. The patient characteristics were age 31.00+/-5.67(21-41) years, BW 72.37+/-10.51 (52.6-117) kg, and ASA physical status 1, 52% for elective and 73% for emergency cases. The indications for operations were mostly CPD, fetal distress and previous cesarean sections. The anesthetic time was 59.19+/-17.35 (35-145) minutes while the induction-delivery time was 12.72+/-5.66 (3-28) minutes. General anesthesia was rapid sequence induction with propofol or thiopental and tracheal intubation under succinylcholine with the application of cricoid pressure. The depth of anesthesia was maintained with 1.5-3% sevoflurane until delivery and the volatile agent was lowered to 0.4-1%, adjusted to clinical manifestation. Midazolam and morphine were added postdelivery. Data of hemodynamic changes during delivery, neonatal outcome and intraoperative blood loss were analyzed without any remarkable note. The postoperative interview on recalls confirmed adequate depth of anesthesia. It was concluded that sevoflurane at more than 1% concentration could be used predelivery in cesarean sections on the issues of awareness, hemodynamics and fetal conditions but caution was suggested in terms of uterine relaxation effect which was dose-dependent.

Perianal blockage with 0.5% bupivacaine for postoperative pain relief in hemorrhoidectomy.

Hemorrhoidectomy can be done in many positions under many anesthetic techniques as an ambulatory surgery. Post-procedural pain is frequently severe enough to delay home discharge. A combination between preincisional local anesthetics and general anesthesia looks attractive in terms of preemptive analgesia and starting time of surgery. The study aimed to compare anesthetic time, pain-free period and pain relief in patients with and without 0.5% plain bupivacaine infiltration after mask inhalation, total intravenous anesthesia or endotracheal tube general anesthesia. MATERIAL AND METHOD: 142 patients were randomized into control (C) and study (S) groups with n = 70 and 72 respectively. Patient characteristics in both groups were: age 40.45 +/- 13.03 VS 37.48 +/- 13.63 years old, BW 59.77 +/- 11.19 VS 58.80 +/- 9.76 kg, male:female 31/39 VS 43/29, PS 1/2/3/E = 48/19/1/2 VS 53/15/3/1 for C and S respectively. All underwent surgery in lithotomy under ET/TIVA/mask: 53/13/4 VS 22/27/23 and anesthetic time was 49.02 +/- 18.04 VS 33.33 +/- 10.31 min (p < 0.05). RESULTS: Pain-free periods in C and S were 204.44 +/- 878.07 and 540 +/- 298.03 min with median times of 57.5 (n = 67) VS 560 (n = 58) min. Pain severity in S was mainly none or mild degree while in C it was moderate or severe, apparently when analysed in subgroups of ET and TIVA. Analgesic requirements were statistically more in group C. CONCLUSION: Better postoperative pain relief could be accomplished by preincisional 0.5% plain bupivacaine infiltration after general anesthesia. The technique helped relax anal muscles for surgical ease and avoided patient discomfort in case of a prolonged procedure. Preemptive analgesia and key pain management were discussed.

Propofol-based fast-track for ambulatory surgery.

The purpose of this study was to provide data of propofol-based total intravenous anesthesia (TIVA) for ambulatory surgery in developing a fast-track technique. One hundred and forty-two patients scheduled for elective surgery were studied: mean (SD) age 42.21 (16.23) years, male to female 72:70, mean (SD) body weight 60.75 (11.67) kg and American Society of Anesthesiologists (ASA) physical status I/II/III 66/38/38. Mean (SD) thiopental induction 225 (55.69) mg was maintained with mean (SD) propofol 199.64 (86.26) mg for mean (SD) anesthetic time 29.02 (11.21) minutes. Various narcotics were used: fentanyl 73.48 +/- 24.38 microg for 123 cases, morphine 3.27 +/- 1.10 mg for 10 cases, remifentanil 492 +/- 105.26 microg for 7 cases and pethidine 23.33 +/- 2.88 mg for 2 cases. Midazolam was given 2.70 +/- 1.05 mg. Patients were positioned in supine, lithotomy or lateral decubitus. One-fourth were PS III with a diagnosis of chronic renal failure and renal transplants coming for incision and drainage of perianal abscess. The mean (SD) wake-up time was 36.02 (17.69) seconds. Only one case (chronic renal failure) had severe hypotension after induction. Anesthetic agents and ideas of fast-track anesthesia were discussed.

A comparison of the efficacy of cisatracurium and atracurium in kidney transplantation operation.

Cisatracurium is a new intermediate-acting benzylisoquinolinium neuromuscular blocking agent that is one of the ten stereoisomers contained in atracurium besylate. Atracurium is known to be the muscle relaxant of choice in end stage renal disease patients. This study aimed to compare the efficacy of cisatracurium and atracurium in the aspect of intubation and maintenance dosages, hemodynamic response after intubation and cost effectiveness between the two agents in kidney transplant patients. MATERIAL AND METHOD: From August 2001 to July 2002, 46 end stage renal disease patients obtained kidney transplantation operation under general anesthesia with 50:50 N2O:O2, fentanyl, isoflurane anesthesia. Tracheal intubation and maintenance of muscle relaxant with each drug were administered in 23 of each group-atracurium as control (C) while cisatracurium was the study (S) group. RESULTS: There was no difference in the demographic data of the 2 groups--13 males/10 females in the S group and 11 males/12 females in the C group. Eighty-seven per cent in the S group underwent living-related kidney transplantation operation, with 55.56 per cent in the C group. Most of the donors were siblings, i.e. 42.11 per cent in the S group and 46.67 per cent in the C group. The mean dosage for intubation in the S group was 0.17 +/- 0.02 mg/kg and 1.25 +/- 0.49 microg/kg/min for maintenance. The mean dosage for intubation in the C group was 0.64 +/- 0.07 mg/kg and the mean maintenance dose was 5.38 +/- 0.83 microg/kg/min. In both groups there was no statistical difference in hemodynamic changes. One patient in the S group received calcium channel blocker to reduce blood pressure before induction of anesthesia, while 2 patients in the C group were given nifedipine 5 mg before induction. Although the cisatracurium cost was higher than atracurium, from the cost-minimization analysis, it turned out to be lower per case. CONCLUSION: This study demonstrated the efficacy of cisatracurium in hemodynamic stability and safety in kidney transplantation operations. In spite of the more costly price, cisatracurium is beneficial in some end stage renal disease (ESRD) patients with coronary artery disease who need very stable hemodynamics.