Popliteal sciatic nerve block aided by a nerve stimulator: a reliable technique for foot and ankle surgery.

The reliability of popliteal sciatic nerve blocks was prospectively assessed in 625 blocks performed in 507 patients. The sciatic nerve was approached at the apex of the popliteal fossa, in the midline, with an insulated needle connected to a peripheral nerve stimulator partially designed by one of the authors. When needed, an inguinal paravascular femoral nerve block was also performed. The drugs used were 1% mepivacaine or 0.5% bupivacaine with or without 1:200,000 epinephrine. The sciatic and femoral nerves were blocked with 30 ml and 10 ml of local anesthetic, respectively. The block was sufficient to provide surgical anesthesia in 92%; supplemental analgesia was necessary in 5% and general anesthesia was required in 3% of the cases. Discomfort associated with the block procedure was found to be minimal by 89% of the patients, moderate by 9% and severe by 2%. Overall satisfaction with perioperative analgesia was evaluated by 466 patients: 444 (95%) were completely satisfied, 20 (4%) expressed moderate reservations and two (1%) expressed major reservations. The authors conclude that the technique is a safe and reliable alternative to more common forms of anesthesia for surgery below the knee. They attribute the great success rate to a high popliteal approach, the use of insulated needles, a discriminating mode of nerve stimulation and the systematic search for optimal response to needle stimulation.

Mortality and morbidity conferences in a teaching anesthesia department.

In our anesthesia department, Morbidity and Mortality conferences (M & M's) evolved from a well established system of voluntary reporting of anesthesia related incidents. They were however not restricted to accidents solely attributable to anesthesia. Between May 1983 and December 1989, 160 cases were presented, usually by the resident or consultant in charge of the patient at the time of event. The format of conferences is described in detail in this paper. Despite an active selection process, the case mix of presentations closely reflected that of major epidemiological surveys of complications in anesthesia. Residents attending regularly M & M's during the five years of their specialty training got an accurate picture of anesthesia-related mishaps, their mechanisms of onset and their outcome. In particular, the important role played by human intervention was clearly underlined. Due to the selection process, interaction with other physicians or health professionals were described with great frequency in the genesis of accidents anesthetists had to deal with. M & M's proved a valuable teaching tool, but also contributed to improve patient care by revealing faulty routines.

Latex allergy in a child: report of a case.

A case of life-threatening anaphylactic shock in a boy undergoing complex urologic surgery under combined general and epidural anesthesia is described. Latex allergy was suspected and later confirmed by a positive RAST for latex. A short review about latex allergy, its diagnosis and prevention is presented.

Intraoperative hemodynamic modifications during pediatric orthotopic liver transplantation.

OLT is generally associated with important cardiovascular changes occurring during the vascular clamping and at the time of revascularization of the newly transplanted liver. In our series of 60 OLT performed in 52 children, the IVC clamping is generally followed by a fall in the PAP and the PWP, the SBP remaining fairly stable in half of the cases. This good tolerance is confirmed by the fact that a veno-venous bypass was used only in 3 instances and vasopressive drugs were needed in only 6 cases. At unclamping, a severe decrease in SBP is associated with a sharp rise in PAP and PWP in most of the cases, whereas some hypovolemic patients decrease their SBP, PAP and PWP. Therefore, we believe that adequate fluid replacement under careful monitoring of the filling pressures provides a good hemodynamic stability in most of the children during the different stages of OLT.

Sudden complications in regional anesthesia.

In regional anesthesia sudden and severe complications occur from time to time and may rapidly turn into life threatening situations. Their rarity might well be their most vicious characteristic. Therefore, awareness of the possible complications, careful preparation to cope with them, vigilance enabling prompt recognition of their occurrence and quick administration of the appropriate treatment are all essential for a safe practice of regional anesthesia. The routine use of pulse oximetry is now strongly recommended.

A new lormetazepam galenical formulation for sublingual premedication.

This study reports a double-blind evaluation of a new formulation of lormetazepam for sublingual administration, given as a premedicant in 48 female patients undergoing minor gynecological procedures. Both patient's and nurse's assessments for anxiety and sedation were recorded at different times. Anxiolysis and sedation were present 30 minutes after administration of the drug as reported by the patient with a peak effect at 45 minutes. Nurses reported significant differences in sedation only, but already present at 30 minutes after premedication. The memory test showed no persistent effect of the benzodiazepine one day after surgery.

Anesthetic experience in adult and pediatric orthotopic liver transplantation.

The authors report their experience with orthotopic liver transplantation in 8 adults and 6 children operated during a 14 months period. The anesthetic technique is described and three points of it are underlined: Renal failure is prevented by a systematic low-dose dopamine infusion added to optimal preloading and mannitol given during the anhepatic phase. Donor liver flush via the portal vein with lactated Ringer's solution is checked by serial measurements of K+ concentration in the fluid draining from the infrahepatic vena cava: the flush is assumed adequate if that K+ level is less than 10 mmoles/l. The risk of air embolism at the time of unclamping is minimized by discontinuing N2O, adding a mild PEEP and placing the patient in Trendelenburg position. The values of hemodynamic and metabolic measurements are given and discussed. There was no peroperative mortality.

Anesthetic protocol in human renal transplantation: twenty-two years of experience.

This paper reviews the experience of 22 years of transplantation. From June 1963 to December 1984, 1362 human renal grafts were performed in our center. Throughout this period, advances in surgical techniques, kidney preservation methods and immunosuppressive regimen have improved patient and graft survival. Simultaneously, progress in anesthetic monitoring and techniques (particularly the use of new muscle relaxants and isoflurane) led to better and safer surgical conditions. A protocol of maximal intraoperative hydration using pulmonary arterial pressure monitoring was progressively developed. This protocol has allowed to reduce significantly the incidence of delayed graft function.

A safe alternative to awake intubation in neonates.

The authors present a retrospective study on the safety of their induction technique of anaesthesia in infants less than 30 days old. The records of 197 consecutive cases are reviewed, 47 of which concern major cardiac surgery. All the details of the technique are given: inhalation of halothane in O2 following a vagolytic premedication, spray of lidocaine 2 mg/kg on the vocal cords, orotracheal intubation to check adequacy of foreseen tube size, followed by definitive nasal intubation with the tube passed over a siliconed suction catheter. The results are discussed. The use of combined general and topical anaesthesia makes endotracheal intubation of the neonate nice and easy, atraumatic, well suited for training and more humane. Awake intubation should only be used as a resuscitative measure.

Craniofaciosynostosis: anesthetic and perioperative management. Report of 71 operations.

Faciocranial dysmorphisms are at the present time corrected during very complex procedures aiming at functional, esthetic and psychological improvement. The authors present their 9 years experience of 71 operations. The age at which those operations are performed is between 6 and 12 months for 14 patients (20%) and under 6 months for 34 patients (48%), the youngest patient being 6 weeks old. Per- and post-operative problems are reviewed. Mean surgical time is 210 minutes. The anesthetic approach aims at reducing the size of the brain by the use of osmotic diuresis, slight hyperventilation, moderate induced hypotension and semi-sitting position. The hemodynamic monitoring includes for all patients an arterial line and a central venous catheter. Blood loss can be large and sometimes sudden; it amounts in average to 62% of patient's estimated blood volume (12 to 200%). The most frequently encountered complications are cardiac dysrhythmias (mainly bradycardia 15 cases), accidental venous sinus opening (2 cases), post-extubation glottic edema (5 cases) and postoperative cerebrospinal leak (2 cases). No long-term sequelae persist from those incidents. There is neither infection, nor perioperative mortality. From those results, the authors consider that infants with craniofaciosynostosis can be operated upon and their dysmorphy corrected with a low perioperative risk. However successful prevention of complications and functional result depend essentially on a multidisciplinary approach, in well-equipped hospitals.

Uneventful recovery in a case of severe malignant hyperthermia.

Early clinical recognition, confirmed by blood gases analysis has permitted successfull management of a case of severe malignant hyperthermia. The authors stress the crucial importance for the theatres area to be fitted up with a huge crushed ice making device and with a large supply of cold saline solution. Due to the lack of easy and reliable preoperative screening test it is mandatory to put high risk patients on Dantrolene therapy when elective surgery is planned.