Postoperative pain management with ketorolac in facial plastic surgery patients.

OBJECTIVE: To evaluate the benefit of intraoperative locally or intramuscularly injected ketorolac in combination with local anesthetic versus local anesthetic alone on postoperative pain in patients undergoing facial plastic surgery. METHODS: Prospective randomized trial of 140 consecutive patients undergoing facelift, and/or forehead lift at a private facial cosmetic surgery practice by one surgeon. Outcome measurement included the requirement for pain medication (none, morphine, acetaminophen with codeine, or plain acetaminophen) at 1, 12, and 24 hours postoperatively. RESULTS: Ninety-five patients receiving locally injected ketorolac required significantly less postoperative analgesic (p<.05) than both the 20 patients who received intramuscularly injected ketorolac and the 25 patients who received local anesthetic alone at 12 and 24 hours. Those patients receiving no ketorolac required significantly more (p<.05) analgesic 1 hour postoperatively. CONCLUSION: Intraoperative locally injected ketorolac is an effective and safe means of reducing postoperative analgesic requirements.

Difficult intubation and brain-stem anaesthesia.

PURPOSE: To present a case of difficult intubation with brainstem anaesthesia after retrobulbar block with bupivacaine and lidocaine and sedation with midazolam and to point out that close monitoring and timely treatment is important in preventing an unfavourable outcome. CLINICAL FEATURES: An 82-yr-old man with treated hypertension and stable angina was scheduled for cataract extraction. Physical examination revealed a class 2 airway. He had a retrobulbar block after topical tetracaine drops, with bupivacaine 0.5% and lidocaine 2% with hyaluronidase under sedation with 1 mg midazolam. Five minutes after the block, respiration slowed, he became unresponsive and oxygen saturation decreased to 80%. Immediate ventilation with mask without additional oxygen improved saturation. Attempted tracheal intubation failed: the epiglottis could not be visualized despite flaccid jaw and extremities. A laryngeal mask airway was placed which was leaking and adequate ventilation could not be achieved but a second laryngeal mask airway was placed successfully. CONCLUSION: This case emphasizes the need for dose monitoring and personnel capable of managing the difficult airway when intra-orbital anaesthesia is used.

Fiberoptic intubation using anesthetized, paralyzed, apneic patients. Results of a resident training program.

BACKGROUND: There is no consensus about the best way to teach fiberoptic intubation. This study assesses the effectiveness of a training program in which novice anesthetic residents routinely were taught fiberoptic tracheal intubation of anesthetized, paralyzed, apneic patients. METHODS: Eight inexperienced anesthetic residents learned fiberoptic and conventional tracheal intubation simultaneously during their first 4 months of training. All intubations were performed using general anesthesia and muscle paralysis. Of these intubations, 223 (23%) were fiberoptic and 743 (77%) were laryngoscopic. Subsequently, their intubation skills with the two techniques were studied in a prospective, single-blind randomized trial involving 131 elective patients. Intubation times, SpO2, ETCO2, hemodynamic changes on intubation, and complications were recorded for 71 fiberoptic and 57 laryngoscopic intubations. RESULTS: There were two failures of the rigid and one failure of the fiberoptic technique due to inability to intubate within 180 s. In cases of failure, the tracheas were intubated successfully after mask ventilation by the alterative technique. No hypoxemia or hypercarbia occurred in any patient. There were no differences in hemodynamic indexes nor incidence of sore throat or hoarseness between the two groups. Mean intubation times were 56 +/- 24 s (mean +/- SD) for fiberoptic and 34 +/- 10 s (mean +/- SD) for laryngoscopic (P < 0.001). CONCLUSIONS: Novices taught fiberoptic intubation and rigid laryngoscopic intubation under similar conditions, with similar volumes of experience, learn both techniques well. The safety and effectiveness of this training regimen commend it for inclusion in any residency program.

Trachoma in an omani village - a health care study.

This paper reports the findings of a study carried out on 289 families in rural Oman, to assess the knowledge of trachoma in a defined community, identify the determinants of continued transmission and endemicity of the disease, and to assess the effect of health education provided by medical students.The study identified the prevalence of illiteracy, large family size and overcrowding as potential risk factors. Lack of knowledge in a significant number of families about causes, prevention and transmission of trachoma led to practices that promoted the spread of the disease.We found that episodic health education by medical students did not have any lasting impact on the community. Between families who had received such health education and those who had not, there were few significant differences regarding misconceptions about the disease and undesirable practices.The findings of this study concerning deficiency in knowledge, misconceptions and incorrect practices about trachoma are being utilised to plan a subsequent health education programme for the villagers.

Health understanding and its effect on health outcome.

Literature regarding health belief models, health understanding and their effect on health outcome is reviewed. Aspects of the major elements comprising health understanding - including lay explanations of illness, locus of control and the affective meaning of symptoms - are described. The particular problems posed by utilising these models in a developing Middle Eastern country are discussed, together with the importance of applied research to assess the feasibility of improving health outcome by enhanced health understanding.

The introduction of epidemiology in training future doctors: the oman experience.

This paper highlights the emphasis put on epidemiology in the training of future doctors at Sultan Qaboos University. It describes the special features of the teaching of epidemiology making it needs-oriented with continuous practical application in the field throughout the preclinical period. The students take an active part in planning field studies using their knowledge of epidemiology. Integration of epidemiology with statistics enables the students to analyze and interpret their own data thus obtaining a quick feed-back of the epidemiological studies conducted by them. They apply their knowledge of epidemiology to evaluate the data and formulate intervention programmes.Close collaboration with the Ministry of Health provides an opportunity for the students to orient themselves with the important health problems of Oman and participate in the country's national programs. The scheduling of courses and continuation of application of epidemiology in the clinical years help to reinforce their knowledge of epidemiology and statistics for the clinical period and subsequent postgraduation.

Education in family and community health: the challenge faced by a new medical school.

This paper describes the efforts of the Department of Family and Community Health at Sultan Qaboos University in providing opportunities for the development of 'hands-on' problem-solving skills appropriate for Oman. The curriculum of the Department is discussed, highlighting the unusual emphasis of this discipline in both the preclinical and clinical curriculum of the College of Medicine. The importance of continuous assessment and supervision of students is discussed. Course-work in the preclinical curriculum of the Department is kept to a minimum. Field-work forms an important part of preclinical training, where application and problem-based learning are emphasized. During the clinical years the students are exposed to an integrated series of lectures and practicals covering core knowledge in clinical medicine. Practical clinical training, over a total period of 15 weeks, takes place at a variety of sites where common problems in primary health care in Oman are handled by students under supervision.

Pharmacokinetic and metabolic aspects of the moclobemide-food interaction.

The effect of a protein-rich meal on the pharmacokinetics of moclobemide was studied after intravenous (75 mg) and oral (100 mg) administrations of this selective MAO-A inhibitor to eight healthy male volunteers. The meal chosen did not affect plasma concentration-time curves of the drug after oral administration apparently, because the influence of blood flow changes to the liver on hepatic first-pass metabolism (AUC increases) and on systemic clearance (AUC decreases) balance each other out.

Prophylactic intramuscular ephedrine before epidural anaesthesia for caesarean section: efficacy and actions on the fetus and newborn.

The authors studied the effectiveness of ephedrine given intramuscularly before epidural anaesthesia with bupivacaine 0.5 per cent in three groups of patients undergoing elective caesarean section. The patients received intramuscular saline as a placebo, ephedrine 25 mg or ephedrine 50 mg, 15 to 30 minutes before anaesthesia. The incidence of hypotension was 8 to 12 per cent in all three groups. Prophylactic intramuscular ephedrine did not lower the incidence of hypotension significantly. Intramuscular ephedrine 50 mg caused a persistent hypertension in eight out of 12 patients and was associated with an increase in umbilical artery [H+] (decrease in pH). No differences were observed in other indices of neonatal well-being. The prophylactic use of intramuscular ephedrine before epidural anaesthesia for caesarean section is not recommended.

Effect of food on lidocaine kinetics: mechanism of food-related alteration in high intrinsic clearance drug elimination.

The effect of high-protein meal on the hepatic clearance (ClH) of intravenous lidocaine, because of its conceptual importance in understanding first-pass metabolic phenomena, was evaluated in nine healthy males. Our randomized crossover study demonstrated that mean ClH rose from 1245 to 1477 ml/min (P less than 0.03) as a result of the meal (i.e., mean area under the blood concentration-time curve decreased 20%). The magnitude of the change in clearance correlated weakly with fasting ClH (r = 0.54; slope = -0.037% per ml/min; intercept = 67.2%; P less than 0.15). In a separate study, it was observed that the meal did not influence lidocaine serum protein binding; the free fraction of lidocaine in samples drawn from the subjects in the fasting state averaged 0.305 +/- 0.027 while that from subjects who had eaten was 0.321 +/- 0.042. These data suggest that the mean clearance of lidocaine is increased by stimulation of hepatic blood flow rate. Furthermore, the magnitude of this increase is consistent with expectations based on a simple physiologic model. Thus, these data provide experimental support for the hypothesis that transient increases in splanchnic blood flow rate observed after a high-protein meal may explain apparent improvement of the oral bioavailability of model high intrinsic clearance drugs.

Effect of lateral position and volume on the spread of epidural anaesthesia in the parturient.

The effect of lateral positioning and the volume of drug injected on the spread of epidural anaesthesia was assessed in 131 healthy parturients. Epidural injection for anaesthesia was done at the L3-4 interspace and a catheter was inserted into the epidural space after injection of the drug. The patients were randomly assigned to four groups. The doses used were 12 ml of bupivacaine 0.25 per cent and 6 ml of bupivacaine 0.5 per cent. Patients were kept in the lateral position in which the block was done (Groups I and III) or turned to the opposite side after completion of the epidural injection (Groups II and IV). Sensory levels and maternal assessment of pain relief were determined fifteen to twenty minutes after injection. All assessments were done by a trained observer who did not know to what group the patient had been allocated. Maintenance of the lateral position after induction of epidural anaesthesia is compatible with satisfactory analgesia for labour. Twelve ml bupivacaine 0.25 per cent provides better analgesia than 6 ml bupivacaine 0.5 per cent although the same mass is injected. The quality of analgesia is improved by turning the patients to the contralateral side after injection of 12 ml bupivacaine 0.25 per cent.

Obstetrical anaesthesia practice in the University of Toronto affiliated hospitals and some randomly selected community hospitals.

A questionnaire was designed to determine the type of personnel that provide obstetrical anaesthesia care and the techniques used in the provision of this care. All seven hospitals with an obstetrical unit affiliated with the University of Toronto and seven community hospitals responded. All anaesthetics were given by physicians. Ninety-two per cent of those in University affiliated hospitals and 63 per cent of those in the community hospitals had obtained their specialty qualification. Standards for preoperative assessment and communication with the patients should be similar to those applied to patients receiving anaesthesia for other reasons. It was clear from our survey that pre-anaesthetic assessment of obstetrical patients differs from that advocated for other surgical patients. For vaginal deliveries, epidural analgesia was clearly the preferred choice, Subarachnoid block was rarely used. The majority of anaesthetists did not use a test dose. Eleven per cent in University-affiliated hospitals and 50 per cent in community hospitals sometimes conducted surgical anaesthesia without tracheal intubation for vaginal delivery. More than 60 per cent routinely encouraged their patients to accept general anaesthesia for Caesarean section. The doctors providing neonatal resuscitation may require further training. Surveys such as this are important if standards of anaesthetic practice are to be established.

Evaluating family practice residents with a problem category index.

Using a standard ambulatory coding system as a base, an index of 42 problem clusters encountered in family practice was developed by two Pennsylvania family practice residency programs. Comparisons of frequencies with which these index problems were encountered by physicians in the Family Practice Centers were used to identify the practice patterns of family practice residents and faculty. Analyses of these displays, while largely subjective, produced some interesting general and specific results. The initial study indicates that many problems known to be common in family practice are not identified as such by the physician. When this type of information can be simplified, it is welcomed and found useful by residents and faculty in family practice training programs. A simplified index can be developed and used by any physician without any special equipment.