A prospective randomized comparison of epidural infusion of fentanyl and intravenous administration of morphine by patient-controlled analgesia after radical retropubic prostatectomy.

In a prospective, randomized study, continuous infusion of epidural fentanyl citrate (group E) was compared with patient-controlled intravenously administered morphine sulfate (group P) for analgesia in 66 men after radical retropubic prostatectomy. Although both methods provided satisfactory analgesia, the mean comfort level scores were lower (that is, greater comfort) in group E than in group P at all observation times. The difference in mean resting comfort level scores between groups E and P was statistically significant (P < or = 0.05) at 9 of the 11 observation times. In addition, significant differences in comfort level scores were noted at 8 of the 11 observation times during deep breathing, 5 of 11 during coughing, and 3 of 9 during ambulation. Maximal and minimal comfort level scores recorded by each patient during the course of the study were significantly lower (that is, less pain) in group E than in group P for all four categories of activity. The percentage of patients who reported no pain was significantly higher in group E than in group P at 9 of 11 observation times during resting and 5 of 11 observation times during deep breathing. No significant differences were noted in side effect profiles or duration of hospital stay. In summary, when two effective methods of analgesia used after radical retropubic prostatectomy were compared prospectively, patients who received epidural infusion of fentanyl were more comfortable than those with patient-controlled intravenous administration of morphine, as evidenced by lower mean, maximal, and minimal comfort level scores and a greater proportion of patients with complete relief of pain.

Measurement of lumbar CSF levels of met-enkephalin, encrypted met-enkephalin, and neuropeptide Y in normal patients and in patients with Parkinson's disease before and after autologous transplantation of adrenal medulla into the caudate nucleus.

The levels in lumbar cerebrospinal fluid (CSF) of neuropeptide Y (NPY), methionine enkephalin (Enk), and Enk contained in amino- and carboxy-terminus extended forms (X-Enk) were examined in nine control patients undergoing elective surgical procedures and in eight patients with advanced Parkinson's disease, before and after the autologous transplantation of adrenal medullary fragments into the right caudate nucleus. The levels of CSF Enk and X-Enk before surgery in patients with Parkinson's disease were significantly less than those observed in control patients (Enk, 166 +/- 38 vs 264 +/- 44 pg/ml; X-Enk, 794 +/- 416 vs 1497 +/- 153 pg/ml). NPY levels did not differ (221 +/- 25 vs 193 +/- 23 pg/ml). After surgery, lumbar CSF samples were taken at 6 weeks, 12 weeks, 6 months, and 9 months. Placement of adrenal medullary fragments into the striatum had no effect on the levels of NPY or Enk at any time point. The levels of X-Enk were significantly enhanced only at 12 weeks (1138 +/- 140 pg/ml) but were at presurgical levels again by 6 months. These data suggest that the transplant was not functionally contributing to the CSF levels of these peptides.

Aspiration pneumonitis. Prevention and treatment.

Recognizing the factors that predispose patients to aspiration and identifying the patients who are susceptible to aspiration are the first steps in preventing aspiration pneumonitis. These steps should be followed by pharmacologic and physiologic management. Mechanical ventilatory support, bronchoscopy when indicated, and aggressive fluid management are essential when aspiration does occur.

Interscalene block anesthesia for shoulder surgery.

One hundred patients had major shoulder surgery with interscalene brachial and cervical plexus block anesthesia. Successful anesthesia was obtained by using this method in 82 patients. Failure was the result of incomplete anesthesia in 16 patients or the presence of a complication. Complications from high blood levels of anesthetic included loss of consciousness and respiratory depression in three patients and seizure in one. The block lasted a mean of eight hours, decreasing the need for postoperative analgesic medications. No postoperative medical complication developed. Ninety-one percent of the patients with successful blocks were satisfied with the procedure.

Amine sulfate formation in the central nervous system.

The sulfates of norepinephrine, dopamine (DA), and serotonin (5-hydroxytryptamine [5HT]) are present in the cerebrospinal fluid (CSF) of laboratory animals and humans. The amounts of sulfated amines in human CSF always greatly exceed the amounts of the free amines. The enzyme responsible for sulfation, phenol sulfotransferase (PST) (EC 2.8.2.1), has been detected in the brain tissue of several species, including humans. PST in the human brain has a high affinity for the amines but it is a low-capacity enzyme. Accordingly, sulfation appears to be of greater significance in the economy of the amines under quiescent conditions than during conditions of increased release of transmitter. Recent evidence suggests that a fraction of the conjugated amines in CSF enters from plasma because in the African green monkey, DA sulfate and 5HT sulfate cross the blood-CSF barrier after i.v. injection. In addition, in humans there are no increases in the concentration of amine sulfates from lumbar to ventricular CSF that would also be compatible with a partly peripheral origin for the amine sulfates. However, it appears that at least a portion of the amine sulfates in CSF originate in the central nervous system because the ratios of [CSF amine sulfates]/[plasma sulfates] are never as high after i.v. injection as under basal conditions.

Free and conjugated amines in human lumbar cerebrospinal fluid.

Significant amounts of acid-hydrolyzable conjugates of 3,4-dihydroxyphenylethylamine, norepinephrine, and 5-hydroxytryptamine were detected in lumbar CSF from 22 awake unpremedicated healthy individuals. In the CSF samples, the amounts of conjugated amines almost always exceeded the amounts of free amines, but were less than the amounts of the acid metabolites 3,4-dihydroxyphenylacetic acid, homovanillic acid, and 5-hydroxyindoleacetic acid.

Measurement of prostaglandins in the cerebrospinal fluid in cat, dog, and man.

Prostaglandins are involved in the modulation of various central functions (neurotransmitters and hypothalamic hormone release, thermoregulation, cerebrovascular tone) and their levels increase in pathological situations [subarachnoid hemorrhage (SAH), stroke, convulsive disorders, etc.]. This study, using sensitive and specific antibodies, examined levels of four eicosanoids, prostaglandins E2 and F2 alpha (PGE2, PGF2 alpha); and the metabolites of PGI2, 6-keto-prostaglandin F1 alpha (6-keto-PGF1 alpha), and of thromboxane A2, thromboxane B2 (TxB2), in the cerebrospinal fluid (CSF) obtained atraumatically from three species (human, canine, and feline). An assessment of the methodologic procedures (extraction and radioimmunoassay) was carried out. Human lumbar cerebrospinal fluid was shown to contain PGF2 alpha (15-44 pg/ml), 6-keto-PGF1 alpha (undetectable to 39 pg/ml), and TxB2 (undetectable to 28 pg/ml), whereas PGE2 was undetectable (less than 18 pg) in all cases. In both animals species the eicosanoid concentrations were 3- to 30-fold higher than humans for every prostaglandin examined. Although the prostaglandin profile for a given species remained constant (cat, PGE2:6-keto-PGF1 alpha:TxB2:PGF2 alpha; dog, TxB2:PGE2:6-keto-PGF1 alpha:PGF2 alpha), the absolute levels were found to be lower in the pentobarbital-anesthetized animals than in conscious cats. The correspondence of the prostaglandin profiles found in cerebrospinal fluid with the profiles reported in the literature in brain homogenates for the same species supports the hypothesis that cerebrospinal fluid levels of prostaglandins reflect the relative rates of synthesis in neural tissue.

Intraoperative and external beam irradiation with or without resection: Mayo pilot experience.

At our institution, intraoperative radiation therapy (IORT) with an electron beam has been administered as a single boost dose of 1,000 to 2,000 cGy (rad) in combination with 4,500 to 5,000 cGy (rad) of fractionated external beam irradiation. From April 1981 to July 1983, 50 patients received such treatment, and results are analyzed in detail in this article. All patients had locally advanced disease (initially unresectable for cure, residual after resection, or recurrent), and the main disease sites were gastrointestinal (pancreatic, colorectal, and biliary tumors) and soft tissue (sarcomas). Disease-free survival to date has been excellent in our colorectal and biliary subsets of patients. Although local progression has not been a major problem in patients with unresectable pancreatic lesions, failures in the liver and peritoneal cavity have been excessive, and treatment strategies have been altered in an attempt to decrease the frequency of such failures. Although both short-term and long-term morbidity are acceptable, pilot trials with use of radiation-dose modifiers are planned to determine whether the therapeutic ratio of local control to associated complications can be improved even further.

Assessment of block of the sciatic nerve in the popliteal fossa.

Success of block of the sciatic nerve in the popliteal fossa in 130 patients was assessed by an anesthesiologist at the time of surgery. The patients were evaluated for complications by the anesthesiologist during postoperative rounds and by the orthopedic surgeon at the 1-month follow-up visit. Acceptance of the block by the patient was judged by answers on a questionnaire filled out by the patients after they had gone home. The questionnaire was designed to determine satisfaction with the block, discomfort associated with performance of the block, and whether sensations suggestive of paresthesias or other complications not evident at the time of discharge from the hospital had occurred. Of 119 patients responding to the questionnaire, 105 (88.2%) expressed overall satisfaction with the anesthesia. Two patients described sensations compatible with postoperative paresthesias, and two others described sensations that may have been paresthesias; in none did the sensations last longer than 1 month. Assessment of the blocks by the anesthesiologist in all 130 patients in the study revealed that anesthesia satisfactory for completion of the operative procedure was achieved in 107 (82.3%). General anesthesia was needed in eight patients (6.2%), and in 15 patients (11.5%) intravenous sedation or injection of the site of surgical incision with local anesthesia (or both) was needed.