Anesthesia for a jehovah’s witness with critical anemia from ruptured stomach GIST.

We report a case of a female Jehovah’s Witness admitted to the hospital with concealed rupture of stomach gastrointestinal stromal tumor (GIST) and scheduled for exploratory laparotomy with tumor removal. She was critically anemic and refused to receive all kinds of blood or blood products. We present anesthesia techniques to avoid blood transfusion in this patient, which include deliberate hypotension and acute normovolemic hemodilution.

The efficiency of different adjunct techniques for regional anesthesia.

In the present prospective, randomized controlled trial, 110 unpremedicated patients undergoing orthopedic surgery under regional anesthesia were randomly divided into 5 groups, with 22 patients in each. During the operation, group 1 listened to a pre-recorded explanation and music, group 2 listened to a subliminal sound, group 3 received propofol by patient-controlled sedation (PCS), group 4 received intravenous midazolam, and group 5 was the control group. Patients in the midazolam group were significantly more sedated than the control group at 1 hr into the operation. The group that listened to an explanation and music were significantly less satisfied than the propofol group at the end of the operation and 30 min. postoperatively. An incremental cost-effectiveness ratio showed that if explanation and music are used instead of propofol it would save 299.53 baht per patient, but the patient satisfaction score will be 17.26 points lower than if the more expensive drug is used.

Cuffed oropharyngeal airway in the patients undergoing short surgical procedures.

OBJECTIVE: This study was designed to study the efficacy of Cuffed oropharyngeal airway (COPA) in the patients undergoing short surgical procedures at Siriraj Hospital. MATERIALS AND METHOD: A prospective study of 65 patients, age 15-65 years, scheduled for elective short surgical procedures under general anesthesia were managed with COPA. Lip-mandibular angle distance was used to indicate the appropriate size of COPA. Demographic characteristics, airway assessments, COPA size, insertion time, airway manipulation, complications during COPA insertion, removal and 2 hour postoperative period were recorded. RESULTS: Success rate of COPA insertion were 93.8 per cent and 4.6 per cent at 1st attempt and 2nd attempt respectively. Insertion time was 53.27 +/- 20.07 seconds. There were 84.4 per cent of patients who needed airway manipulation during anesthesia. The incidence of complications were 12.3 per cent, 13.8 per cent and 15.4 per cent during insertion, removal and 2 hour postoperatively respectively. CONCLUSION: COPA is a new adjunctive airway device designed for direct connection with breathing system with a high success rate of insertion. COPA placement is an easy technique to learn but it usually requires a high incidence of airway manipulations such as head turn, jaw thrust, head tilt, and chin lift, so skill and confidence in its use requires instruction and practice. It would be unwise to use a COPA in an emergency without first having become proficient in its use for routine cases.

Can ketamine potentiate the analgesic effect of epidural morphine, preincisional or postincisional administration?

A randomized controlled trial was conducted to determine the effect of adding epidural ketamine to epidural morphine comparing between giving ketamine at preincisional time and postincisional time on postoperative analgesia in patients undergoing gynecological operations. Eighty patients scheduled for gynecological operation under combined epidural-general anesthesia were randomly divided into 4 groups. Group 1 received epidural morphine 3 mg before skin incision. Group 2 received epidural morphine 3 mg after skin incision. Group 3 received epidural morphine 3 mg and ketamine 30 mg before skin incision. Group 4 received epidural morphine 3 mg and ketamine 30 mg after skin incision. Lidocaine 2 per cent with epinephrine 1:200,000 was used as the main anesthetic agent during the operation in all groups. Postoperative analgesics were pethidine 1 mg/kg intramuscularly or paracetamol 1,000 mg oral. The time to the first analgesic requirement and pain during 48 h were recorded. The amount of pethidine and paracetamol required and the time to the first dose of analgesic requirement were not significantly different among the groups. There were no differences in the incidences of pruritus, nausea, vomiting and nightmare. We concluded that adding ketamine to epidural morphine either by preincisional or postincisional administration did not potentiate the analgesic effect of epidural morphine.