Continuous paravertebral block for post thoracotomy analgesia in children.

The use of continuous paravertebral analgesia was studied in 15 children with a mean age of 9.8 years (2-16 years). Nine patients received pre-emptive and postoperative paravertebral analgesia while six children studied earlier in the series received only post operative paravertebral analgesia. Excellent pain relief was attained in all patients, as assessed by the graded pictures of facial expression or visual analogue pain scores and morphine requirements. There were no pulmonary complications and no complications related to the continuous paravertebral infusion of bupivacaine. We conclude that continuous paravertebral block is an effective and safe method for post thoracotomy pain relief in children.

Hearing loss following spinal anaesthesia with bupivacaine.

The purpose of this study was to determine the incidence, degree and reversibility of hearing loss following spinal anaesthesia with bupivacaine and secondarily to see if there is a relationship between post-spinal headache and hearing loss. A prospective series of 35 patients admitted for elective Caesarean section under a standardized spinal anaesthetic was investigated. Otolaryngological examination and pure tone audiometry in the frequency range 250 Hz to 8 KHz were done on the day before surgery and on post-operative days 1 and 5. Five patients developed a reversible sensorineural hearing loss (mean loss 14.6 dB). This loss was either unilateral (3) or bilateral (2) and affected the low frequencies in all five patients. The demographic data for both groups (i.e. no change in hearing/sensorineural loss) was similar for age, weight, height, blood pressure change and level of sensory block. There was no association found with post-spinal headache.

Tumor embolism to LAD during pneumonectomy. A case report.

Arterial embolization from bronchogenic carcinoma is a rare complication and more commonly occurs intraoperatively during pneumonectomy. We report an unusual case of intraoperative tumour embolism to LAD (left anterior descending artery) and aorta during left pneumonectomy due to tumour involvement of the inferior pulmonary vein. High risk cases should be evaluated by preoperative transesophageal echocardiography. If tumour involvement of the inferior pulmonary vein is demonstrated, a modification of the surgical technique or alternative modality of treatment should be used.

A comparison of the effect on gastric emptying of either enflurane or propofol given during maintenance of anaesthesia for minor surgery.

Twenty patients scheduled for minor gynaecological surgery were studied. Anaesthesia was induced with propofol and maintained either with enflurane/oxygen/nitrous oxide or propofol/oxygen/nitrous oxide. The rate of gastric emptying was measured indirectly by the paracetamol absorption model. The results showed that there was no significant difference in gastric emptying rate between the two groups. Recovery in the propofol group was more rapid in that paracetamol ingestion occurred earlier in the recovery period compared with the enflurane group.

Efficacy of pre-emptive analgesia and continuous extrapleural intercostal nerve block on post-thoracotomy pain and pulmonary mechanics.

OBJECTIVE: Thoracotomy results in severe pain and deleterious changes in pulmonary physiology. The literature suggests that these alterations in pulmonary mechanics are inevitable and can only be minimised but not prevented by effective analgesia. We have re-evaluated this concept and assessed the efficacy of pre-emptive analgesia [preincisional afferent block, premedication with opiate and/or non-steroidal anti-inflammatory drug (NSAID)] in conjunction with postoperative extrapleural continuous intercostal nerve block on postoperative pain and pulmonary function. MATERIALS AND METHODS: A prospective randomized study was conducted on 56 patients undergoing elective thoracotomy. Subjective pain relief was assessed on a linear visual analogue scale. Pulmonary function was measured on the day before operation and 12 hourly for 48 hours after operation. There were seven patients in each of the eight groups. RESULTS: The balanced analgesia group comprising preincisional block and premedication with opiate and NSAID (Group 1) had significantly better analgesia, needed less postoperative supplementary analgesics and maintained their preoperative pulmonary function postoperatively irrespective of the nature of the operation. The ranking of importance of the three components of the pre-emptive analgesia as assessed in this study are preincisional block, opiate premedication and premedication with NSAID's. No significant change in plasma levels of cortisol or glucose occurred in Group 1 patients from prior to induction of anaesthesia to 24 hours postoperatively, suggesting effective somatic and sympathetic afferent blockade had been achieved in these patients. There were no complications related to the infusion or the use of NSAID's. CONCLUSIONS: We conclude that a balanced analgesic regime comprising preoperative pain prophylaxis and postoperative maintenance analgesia by NSAID and continuous extrapleural intercostal nerve block will minimise and even reverse the expected decline in lung function after thoracotomy. The postoperative decline in lung function is not obligatory but primarily due to incisional pain and thus is preventable by effective analgesia. An ideal balanced pre-emptive analgesic regime should include preincisional local anaesthetic afferent block and premedication with opiates and a NSAID:

A comparison of the effect on gastric emptying of alfentanil or morphine given during anaesthesia for minor surgery.

Twenty patients, scheduled for minor gynaecological surgery, were studied. Anaesthesia was induced with propofol and maintained with oxygen, nitrous oxide and enflurane. Patients were randomly allocated to two groups: group 1 were given alfentanil 0.2 mg; group 2 were given morphine 5 mg. The rate of gastric emptying was measured indirectly by the paracetamol absorption technique. The results showed that morphine caused greater delay in gastric emptying compared with alfentanil (p < 0.05). The observed effect on gastric emptying rate may potentially affect the risk of peri-operative regurgitation and aspiration. This study provides further evidence that in short day-case procedures, when oral medication may be required postoperatively, alfentanil may be preferable to morphine as an intra-operative opioid.

Comparison of propofol with enflurane during hypotensive anaesthesia for middle ear surgery.

Forty patients undergoing middle ear surgery were allocated randomly to receive propofol induction and maintenance, or thiopentone induction and enflurane maintenance for anaesthesia. Both groups also received fentanyl, alcuronium, nitrous oxide and oxygen. If this did not reduce systolic arterial pressure to 70 mm Hg, labetalol, glyceryl trinitrate (GTN), or both, was administered. Fifteen control patients had enflurane anaesthesia without hypotension. Pre- and postoperative psychometric tests were performed in all groups. The propofol group received significantly more labetalol (P = 0.014) and GTN (P = 0.004) than the enflurane group. There was a greater increase in reaction times after operation in the study groups (P < 0.05) compared with controls. There was no difference between the propofol and enflurane groups in control of arterial pressure, recovery from anaesthesia or psychometric testing.

Continuous intercostal nerve block versus epidural morphine for postthoracotomy analgesia.

Twenty patients undergoing elective thoracotomy were randomized into two groups, receiving either lumbar epidural morphine (n = 10) or continuous extrapleural intercostal nerve block (n = 10). Subjective pain relief was assessed on a linear visual analogue scale. Pulmonary function (peak expiratory flow rate, forced expiratory volume in 1 second, and forced vital capacity) was measured on the day before operation and daily for 4 days after operation. Pulse oximetry monitoring was used to determine the incidence of hypoxemia. No significant difference was observed between the groups concerning pain relief (except at 28 hours, in favor of the intercostal nerve block group), respiratory performance, or arterial oxygen saturation. Vomiting, pruritus, and urinary retention occurred only in the epidural group, whereas nausea occurred significantly less frequently in the extrapleural group. We conclude that after thoracotomy continuous extrapleural intercostal nerve block is as effective as lumbar epidural morphine in reducing postoperative pain and restoring pulmonary mechanics. Because of the significantly lower complication rates we favor continuous extrapleural intercostal nerve block for postthoracotomy analgesia.

Continuous measurements of oxygen saturation during haemodialysis.

A new technique for recording and analysing continuous measurements of oxygen saturation (SpO2) by pulse oximeter during haemodialysis was used to compare changes in SpO2 in eight patients during two 4 h periods of dialysis using a cuprophane membrane, once using an acetate dialysate, and once using bicarbonate. The computer-derived patterns of SpO2 show whether hypoxaemia was caused mainly by extrapulmonary abnormalities (ventilatory control) or intrapulmonary abnormalities (V/Q distribution). The patterns of oxygen saturation were analysed for (i) stability, (ii) the lower median 20th centile of SpO2, and (iii) time below a SpO2 of 90%. Not all patients had reduced oxygenation during acetate dialysis. Three of eight patients had a stable pattern with acetate dialysis and six of eight were stable with bicarbonate. Five of eight patients had a lower SpO2 with acetate but one patient had a lower SpO2 with bicarbonate. Four patients had prolonged, clinically significant periods of oxygen desaturation with SpO2 less than 90%; two of these had particularly prolonged periods during acetate (62 min and 12 min), but one patient showed a longer period during bicarbonate than acetate dialysis (7 min). In two patients the SpO2 declined to less than 84%. The patterns of SpO2 suggested that the decrease in oxygen saturation was due more to extrapulmonary abnormalities causing an instability in ventilatory control rather than to venous admixture. It is recommended that pulse oximetry is used to identify patients at risk of hypoxaemia, to monitor these patients during haemodialysis, and to administer oxygen to those whose SpO2 falls below 90%, particularly if they have anaemia or cardiovascular disease.

Pneumomediastinum during general anaesthesia: a case report.

A case is reported of a pneumomediastinum which presented as an unexplained dysrhythmia during a routine general anaesthestic in a previously fit 19-year-old girl. The possible precipitating factors in this case are discussed along with a description of the signs and symptoms and an outline of its management.

A survey of anaesthetic charts.

This survey reviews the structure and content of all anaesthetic record charts in use in the 40 hospitals of the Yorkshire Regional Health Authority in the light of previous recommendations. Twenty-two different anaesthetic charts were used by 290 anaesthetists in this region. Some of the charts did not meet the ideal standard for size (A4) and the majority had no colour coding. Fourteen of the 22 charts omitted important headings concerned with patient identification and eight charts did not provide a record of the whole perioperative period. Some comprehensive forms are in use, chiefly in smaller hospitals, but there have been few changes in design in the last 10 years despite increasing medicolegal awareness.