Local supplementation of ketoprofen reduces the incidence of low back pain after lumbar epidural anesthesia.

BACKGROUND: Backache is a common postoperative complaint after lumbar epidural anesthesia. Our study was aimed to compare the effect of the local addition of ketoprofen on the incidence of postepidural backache after nonobstetric surgery. METHODS: One thousand patients scheduled for hemorrhoidectomy were randomly given 4 ml of 1% lidocaine with ketoprofen 1:400 (ketoprofen group) or without ketoprofen (control group) for local skin infiltration prior to epidural needle placement. Each of them received a single epidural injection of 25 ml 2% lidocaine with epinephrine 1:200000, and was interviewed 24, 48, and 72 hours postoperatively using a standard visual analog scale (VAS) for evaluation of postepidural backache. RESULTS: The incidence of postepidural backache in the ketoprofen-group patients for the 3 days was 9.8%, 4.6%, and 1.8%, all rates which were significantly less than those observed in the control-group patients (22.8%, 17.4%, and 9.2%, p < 0.001). There was also a significant association between postepidural backache and multiple attempts at epidural needle insertion. CONCLUSION: In summary, the local addition of ketoprofen reduced the incidence and severity of postepidural backache.

Anesthetic management of a parturient implanted with a permanent pacemaker--a case report.

At the present time, a patient with a pacemaker who undergoes an anesthesia for a surgical procedure is very common, but a parturient with a permanent pacemaker scheduled for elective cesarean section (c/s) is very rare. Complete heart block in pregnancy is not a common event and it may be congenital or acquired, particularly secondary to cardiac surgery. In normal women, the heart rate is physiologically increased commensurate with need, whereas in a parturient with installment of an implanted fixed rate pacemaker of VVI mode her heart rate cannot accelerate to cope with increased physiological demand because of the fixed pacing rate. For cesarean section, because of destabilized cardiovascular adaptation, an anesthesiologist must focus on detecting the early signs of compromised cardiac output in order to avoid maternal as well as fetal distress. He may run considerable risk to administer general or regional anesthesia to this kind of parturient. We present a case report in managing the parturient installed a with non-rate response type pacemaker undergoing C/S under epidural anesthesia.

Successful treatment of severe uterine synechiae with transcervical resectoscopy combined with laminaria tent.

Seven patients with secondary amenorrhoea were diagnosed as having severe uterine synechiae by hysterosalpingography (HSG) and hysteroscopy, which revealed short, narrow and/or scarred uterine cavities as cone or column shapes. Laminaria tents were used to distend the uterine cavity prior to transcervical resectoscopy to completely dissect the dense adhesions. A more traditional postoperative management included an intrauterine device, oestrogen and antibiotics. Transcervical resectoscopy combined with laminaria appears to be a safe and effective means of restoring the uterine cavity. All seven patients not only achieved normal menstruation but also normal uterine cavity as confirmed by subsequent HSG and hysteroscopy. In addition, three patients thereafter became pregnant, two of whom have had successful term deliveries.

Absorption of irrigating fluid during transcervical resection of endometrium--a report of two cases.

It has been recognized for many years that the use of hypotonic solution for the irrigation of the bladder cavity during transurethral resection of the prostate (TURP) may result in hyponatremia and water intoxication due to rapid and excessive absorption of the solution from the exposed prostatic bed, the clinical manifestation of which is termed "TURP syndrome". A similar condition termed "female TURP syndrome" following hysteroscopic transcervical endometrial resection (TCR) has been reported. Since the frequency of TCR continues to increase the increased rate of "TCR syndrome" would come in its wake. Here, we present two cases who developed severe hyperglycemia and hyponatremia while underwent TCR with 10% dextrose in water as the irrigation fluid and the same time emphasize the potential risk of this complication.

Unexpected left endobronchial intubation in a case of Turner's syndrome.

Patients with Turner's syndrome present a multiplicity of cardiovascular and airway abnormalities. We describe a case of Turner's syndrome with pericardial effusion who experienced an inadvertent endobronchial intubation due to displacement of the endotracheal tube immediately after the pericardial drainage. A sudden increase of airway pressure and decrease of oxygen saturation in the presence of breathing sound audible via the chest piece placed on the left hemithorax first misled us to call our attention to sputum impaction. No sputum was obtainable from airway suction. Inadvertent bronchial intubation was highly suspected at the post-anesthesia room when a decrease of right side breathing sound was noted together with a progressive fall of oxygen saturation. Emergent chest x-ray confirmed the diagnosis. It was thought that the mishap took place early in the act of or following the pericardial drainage. Our case serves as evidence once again to emphasize the possibility of endobronchial intubation due to displacement of endotracheal tube during anesthesia and the importance of monitoring to guard against inadvertent bronchial intubation, particularly in patients with associated problems such as Turner's syndrome with huge pericardial effusion.

[The blood pressure of upper and lower extremities in parturients under spinal anesthesia for cesarean section].

BACKGROUND: In clinical practice, we only measure the blood pressure of the arm during cesarean section. However, it can not accurately reflect the real image of pressure of the lower extremity in labor women. Therefore, we recorded simultaneously the arm and leg blood pressure in the term parturients undergoing cesarean section under spinal anesthesia. METHODS: After hydration with 1500 ml lactated Ringer's solution, all patients received spinal anesthesia with 2ml (0.5%) spinal heavy bupivacaine. The right hip was elevated 15 degree to insure left uterine displacement. Prior to spinal block blood pressure of the arm and leg was measured and recorded simultaneously using a Criticon Dinamap vital sign monitor 1846sx and was continued in determination every minute thereafter until uterine incision. RESULTS: We found that monitoring the lower extremity blood pressure might detect the onset of systemic hypotension more earlier and in some instances is disclosed hypotension that was not even detected by the arm cuff monitor. In addition, we found that the blood pressure in the leg was higher than that in the arm, but when hypotension occurred, it might fall even lower than that of the arm. CONCLUSIONS: We suggest that monitoring blood pressure in cesarean section under spinal anesthesia should be minute to minute for the first ten minutes and one had best monitor the lower extremity blood pressure in order to promptly detect hypotension.

Experience of epidural blood patch for post-dural puncture headache.

Post-dural puncture headache is a common outcome following either spinal or epidural anesthesia. Cases were collected within five years' period (1988-1992) in Keelung Chang Gung Memorial Hospital. Those cases with relief of post-dural puncture headache after conservative treatment were excluded. There were 159 cases, 128 female patients and 31 male patients. Age ranged from 16-63 yrs. Post-dural puncture headache was observed in 145 patients receiving spinal anesthesia and 14 patients receiving epidural anesthesia. Volume of autologous blood for epidural blood patch ranged from 10 to 20 ml. Effective rate was 98.15% upon single blood patch. Repeated blood patch was done in 3 cases. No complication was noted.

[Pain control for liver transplants].

Liver is the largest organ and is located in the right upper quadrant of the abdominal cavity. Surgery for liver transplantation is performed through a large skin incision, which gives considerable pain post operatively. We experienced 10 cases of liver transplant, 3 cases used meperidine 0.5 mg/kg intramuscularly, 3 cases used epidural morphine analgesia, and for the remainder 4 cases, we used morphine 2-3 mg intravenously as needed. Liver transplantation is a major surgery. It attracts media for reporting. The hospital administrator realized its importance to the hospital. A 24 hours special nursing team was provided. Addition analgesic medication was given intravenously in a bolus dose of 2-3 mg of morphine. All patients were able to communicate freely with the nursing team. The communication between the patient and nursing team is free. No post-analgesic hypotension or dyspnea were noted. Patients in all three groups were equally satisfied with their analgesic therapy post-operatively. As all patients expect pain after surgery, they were satisfied when the pain was less than what they had anticipated. Blood gases analysis was however better in patients with epidural morphine analgesia.

Influence of epinephrine as an adjuvant to epidural morphine for postoperative analgesia.

The influence of the addition of epinephrine to epidural morphine on postoperative analgesia were investigated in 60 ASA physical status I or II patients aged average 45 yr. The treatments were given following lower extremity operation under epidural anesthesia with 2% Xylocaine solution in 20 mL. The subjects were randomly divided into 2 groups. Group A (n = 30) received 2 mg epidural morphine in 10 mL normal saline without epinephrine. Group B (n = 30) received 2 mg epidural morphine in 10 mL normal saline with epinephrine 0.1 mg (1:100,000, 10 micrograms/mL). Patients were assessed for quality and duration of postoperative analgesia, as well as the incidence and severity of side effects after epidural morphine administration. The addition of epinephrine to epidural morphine had significantly increased the quality and duration of analgesia. The side effects of pruritus, nausea, vomiting, and urinary retention were more intense after epinephrine-morphine administration. However, respiratory depression was not observed in both groups.

Rapid sequence induction and tracheal intubation with vecuronium--with or without a priming dose.

The purpose of this study was to determine whether prior administration of a small, sub-paralytic dose of nondepolarizing muscle relaxant, vecuronium, would have a better intubating condition than a single bolus dose when vecuronium was used as the muscle relaxant during rapid sequence induction and tracheal intubation. Six groups of 15 patients each (ASA class I or II) were involved in this study. Anesthesia was induced with fentanyl 2-3 micrograms/kg and thiopental 4-5 mg/kg. In group 1, 2 and 3, the patients were given the same priming dose of 0.1 mg/kg. Four min later, different doses of vecuronium were given to each group: 0.09 mg/kg (Gp1), 0.14 mg/kg (Gp2), and 0.19 mg/kg (Gp3). In group 4, 5 and 6, no priming vecuronium was given and the intubating doses given to each group were as follow: 0.1 mg/kg (Gp4), 0.15 mg/kg (Gp5) and 0.2 mg/kg (Gp6). At the end of a 60 sec, the percentage of patient with excellent intubating condition were 46.6%, 66.6%, 86.6%, 20%, 40% and 80% respectively for group 1, 2, 3, 4, 5 and 6 respectively. The percentage with good intubating condition were 46.6%, 33.4%, 13.4%, 46.6%, 53.2%, and 20% for group 1, 2, 3, 4, 5 and 6 respectively. The percentage of poor intubating condition were 6.8% in group 1, 33.4% in group 4, 6.8% in group 5 and 0% in group 2, 3, 6. All patients receiving a priming dose could sustain head lift for 5 sec and did not complain any respiratory discomfort 3 min after the priming dose.(ABSTRACT TRUNCATED AT 250 WORDS)

Endotracheal lidocaine instillation in pediatric anesthesia.

The purpose of this study is to evaluate the effectiveness of lidocaine administered via the endotracheal tube in suppressing cough reflex during anesthetic recovery in children. Fifty ASA class I-II children, aged from 1-5 years old undergoing elective abdominal or urogenital surgery were randomly assigned into two groups. 2% lidocaine 1.5 mg/kg (1ml = 20mg) was administered in group B while normal saline (N/S) 0.1 ml/kg was used in group A (control group). Either one of the agents was instilled into the endotracheal tube right before the end of operation. Airway responses and other associated phenomena were recorded during the recovery period. Recovery condition was categorized into a two-grade categories, namely "good", and "poor" to denote the quality of recovery. Recovery conditions differ significantly between the control group and the experimental group. In group A, 3 patients were classified as the "good" grade but 22 patients were categorized in the "poor" grade. Group B (lidocaine 1.5 mg/kg) has a much better recovery condition than the control group, there were 19 in the "good" grade and only 6 in the "poor" grade. The experimental group treated with 2% lidocaine presented a significantly better recovery than the control group. This effective suppression of the cough reflex might be due to the local anesthetic effect exerted by lidocaine. For the sake of safety all patients were closely followed up at the post anesthesia room until the return of consciousness and laryngeal reflexes. In conclusion, we found that 2% lidocaine 1.5 mg/kg given intratracheally via the endotracheal tube could attenuate cough response during recovery in pediatric anesthesia.

Liver transplantation in Taiwan: the Chang Gung experience.

Between March 1984 and February 1991, six orthotopic liver transplantations were performed at the Chang Gung Memorial Hospital in Taiwan. The indications for transplantation were Wilson's disease (5 patients) and biliary atresia (1 patient). Donors and recipients were matched only for size and ABO blood group compatibility, and the recipient operations were performed without the use of a venovenous bypass. Arterial reconstruction was carried out by end-to-end hepatic artery anastomosis (4), thoracic aortic conduit (1), or interposition of an iliac artery graft (1), whereas biliary reconstruction was accomplished by a choledochocholedochostomy using a T-tube stent (4) or a choledochocholedochostomy using an external cholecystostomy without stenting (2). Biliary complications occurred in three patients, and all required additional surgery. The average duration of donor-liver cold ischemia, operating time, and blood loss during surgery were 7 h and 50 min (range, 4.5-9 h), 13.5 h (range, 11.8-17 h), and 4,385 ml (range, 750-12,000 ml), respectively. The immunosuppressive regimens included a cyclosporin-steroid combination (n = 2) and a triple-drug combination (n = 4). All except one of the surviving patients experienced at least one rejection episode that was reversed by a methyl-prednisolone bolus and/or recycle. One patient developed a primary cytomegalovirus (CMV) infection that responded well to Ganciclovir treatment. Two of the patients died, one of injuries sustained in a traffic accident 3 years after transplantation, and the other of massive upper gastrointestinal bleeding. The overall survival value at 3 months was 83%, and the follow-up period ranged from 3 months to 7 years. All of the survivors have achieved complete rehabilitation and currently enjoy an excellent quality of life with normal liver function. Although the present study involved a small number of cases, our results indicate that liver transplantation can be successfully achieved in a high proportion of patients with acceptable morbidity, mortality, and cost in an Asian setting. The extreme shortage of donor organs is currently the most important obstacle limiting the application of liver transplantation in Taiwan.

The laryngeal mask airway--clinical experience.

The laryngeal mask airway (LMA), a new type of airway, when it is inserted blindly into the hypopharynx forms a seal around the larynx and allows easy and convenient spontaneous or controlled positive pressure ventilation. A clinical application of the LMA to 70 surgical patients in our hospital have been evaluated. LMA was successfully applied to 68 (97%) patients who all received general anesthesia with unobstructed controlled ventilation. The patency of the airway did not change throughout the course of anesthesia. There were 2 patients whose airway was obstructed at the first attempt due to downfolding of epiglottis; in one of them the obstruction was confirmed by flexible fibreoptic laryngoscopy. Subsequent placement was successful in these 2 patients. Insertion failure was seen in 2 patients respectively due to small mouth and excessive salivation. The placement of LMA does not require laryngoscopy and there is no fear of misplacement in the esophagus. It becomes obvious that the LMA would substantially gain a place in the armamentarium in anesthesia and we think that its use would be of interest to anesthesiologists.

Incidence of post-dural puncture headache with 25-gauge Quincke spinal needle.

A retrospective study was undertaken in patients who received spinal anesthesia in past two years in order to find out the incidence of post-spinal headache. There were 3729 cases, 1997 males and 1732 females. Seventy-two patients were noted to have post-spinal headache of whom twelve were male and sixty were female. The overall incidence was 1.93%. Incidence was 0.6% and 3.5% in male and female groups respectively. With respect to the type of surgical procedures in female group, patients undergoing Cesarean section had a higher incidence than those who received other surgical procedures, being 4.8% and 1.5% respectively. In conclusion, female patients were noted to have higher incidence of post-spinal headache, particularly in patients undergoing Cesarean section.