Addition of ketamine to propofol for initiation of procedural anesthesia in children reduces propofol consumption and preserves hemodynamic stability.

BACKGROUND: There is no ideal anesthesia protocol to perform short invasive procedures in pediatric oncology. The combination of propofol and ketamine may offer advantages over propofol alone. METHODS: In a prospective, randomized, double-blind study, we analyzed 63 consecutive procedures performed in 47 oncology children. All patients received 1 mug/kg fentanyl, followed by propofol 1 mg/kg in group P (n=33) or propofol 0.5 mg/kg and ketamine 0.5 mg/kg in group PK (n=30) for the initiation of anesthesia. The need for supplementation with propofol and/or fentanyl to maintain an adequate level of anesthesia was recorded. The hemodynamic and respiratory profile, recovery time and the occurrence of side effects were compared. RESULTS: Significantly more children required propofol (100% vs. 83.3%) and fentanyl (75.5% vs. 43.3%) rescue doses, and developed hypotension (63.6% vs. 23.4%) and bradycardia (48.5 vs. 23.4%) in group P compared with group PK, with a comparable incidence of respiratory adverse events and recovery times. However, 40% of children in group PK were agitated following recovery compared with 6% in group P. CONCLUSIONS: The combination of propofol and ketamine for invasive procedures in pediatric oncology resulted in reduced propofol and fentanyl consumption and preserved hemodynamic stability, but more children in the combination group recovered with agitation.

Effect of low-dose dexmedetomidine or clonidine on the characteristics of bupivacaine spinal block.

BACKGROUND: The purpose of this study was to compare the onset and duration of sensory and motor block, as well as the hemodynamic changes and level of sedation, following intrathecal bupivacaine supplemented with either dexmedetomidine or clonidine. METHODS: In a prospective, double-blind study, 60 patients undergoing transurethral resection of prostate or bladder tumor under spinal anesthesia were randomly allocated to one of three groups. Group B received 12 mg of hyperbaric bupivacaine, group D received 12 mg of bupivacaine supplemented with 3 microg of dexmedetomidine and group C received 12 mg of bupivacaine supplemented with 30 microg of clonidine. The onset times to reach peak sensory and motor levels, and the sensory and motor regression times, were recorded. Hemodynamic changes and the level of sedation were also recorded. RESULTS: Patients in groups D and C had a significantly shorter onset time of motor block and significantly longer sensory and motor regression times than patients in group B. The mean time of sensory regression to the S1 segment was 303 +/- 75 min in group D, 272 +/- 38 min in group C and 190 +/- 48 min in group B (B vs. D and B vs. C, P < 0.001). The regression of motor block to Bromage 0 was 250 +/- 76 min in group D, 216 +/- 35 min in group C and 163 +/- 47 min in group B (B vs. D and B vs. C, P < 0.001). The onset and regression times were not significantly different between groups D and C. The mean arterial pressure, heart rate and level of sedation were similar in the three groups intra-operatively and post-operatively. CONCLUSIONS: Dexmedetomidine (3 microg) or clonidine (30 microg), when added to intrathecal bupivacaine, produces a similar prolongation in the duration of the motor and sensory block with preserved hemodynamic stability and lack of sedation.

Laparoscopic splenectomy in a patient with acquired angioneurotic edema.

BACKGROUND: We report the case of a 77-year-old female with acquired angioneurotic edema, C1 esterase inhibitor level = 4mg/dL, who was scheduled to undergo laparoscopic splenectomy. METHODS: In the operating room, we administered on call 500 units (UI) of C1 esterase inhibitor concentrate intravenously. Intraoperative hemodynamic instability and generalized blood oozing improved following the administration of aprotinin 250000 UI intravenous (IV) drip. CONCLUSION: We recommend the administration of an antifibrinolytic agent in addition to C1 esterase inhibitor concentrate in patients with acquired angioneurotic edema.

Anaphylactic shock complicating laparoscopic treatment of hydatid cysts of the liver.

Hydatid cysts of the liver have been treated surgically for many years by several surgical techniques including evacuation, marsupialization, and filling the cyst with saline after evacuation of the endocyst. We have previously reported laparoscopic treatment of hydatid cysts using the same hydatid asepsis and surgical techniques as in open surgery, with comparable results. Spillage of hydatid fluid during open surgery has been shown to result in serious anaphylactic reaction. The present report describes the first case report of such a reaction during laparoscopic treatment of hydatid cyst of the liver.

Correlation of the end-tidal PCO2 during laparoscopic surgery with the pH of the gastric juice.

BACKGROUND AND OBJECTIVES: During laparoscopy, the increase of the carbon dioxide tension may increase the synthesis of hydrochloric acid in the parietal cells of the stomach; the source of the secreted hydrogen ions is carbonic acid derived from the hydration of carbon dioxide. The present report tests this hypothesis by correlating the changes of end-tidal PCO2 (ETCO2) with the pH of the gastric juice in patients undergoing laparoscopic cholecystectomy. METHODS: 40 adult patients were investigated: 20 controls, and 20 patients receiving 100 mg nizatidine intravenously, prior to surgery. In both groups, the ETCO2 was measured by capnography and the pH of the gastric juice was monitored before carbon dioxide insufflation and at the end of laparoscopy prior to carbon dioxide deflation. RESULTS: In the control group, the ETCO2 increased following carbon dioxide insufflation from a mean basal value of 30.2 (standard deviation [SD] 4.6) mm Hg to 41.1 (SD 9.5) mm Hg, while the mean pH of the gastric juice decreased significantly from 1.9 (SD 0.4) to 1.27 (SD 0.43). There was a significant negative correlation between the ETCO2 and pH of the gastric juice (r = -0.4). In the Nizatidine group, the ETCO2 also increased following carbon dioxide insufflation from a mean basal value of 30.9 (SD 3.0) mm Hg to 39.4 (SD 5.3) mm Hg. However, in contrast with the control group, the mean pH of the gastric juice did not decrease, but paradoxically increased from 1.68 (SD 0.36) to 3.6 (SD 1.02). CONCLUSIONS: During laparoscopy, the pH of the gastric juice is significantly decreased. This decrease is inversely related to the increase of ETCO2. The preoperative administration of the selective H2-blocker nizatidine can prevent the increase in gastric acidity and can result in a paradoxical increase of pH of the gastric juice.

Results of laparoscopic treatment of hydatid cysts of the liver.

BACKGROUND: We have previously reported on the laparoscopic treatment of hydatid cysts of the liver. We now report the successful treatment of 18 cysts in 12 patients with a median follow-up of 12 months. METHODS: The standard treatment in the open technique was performed laparoscopically. The main concern was to prevent spillage of the hydatid fluid, for which the puncture and evacuation of the cyst is carried under scolicidal agents cover using 1% cetrimide, thus decreasing the chances of recurrence. RESULTS: In this group of patients we had one biliary leak that ceased spontaneously and one recurrence of hydatid cyst but not in the same lobe. CONCLUSIONS: We conclude that laparoscopic evacuation of hydatid cysts is a successful operation comparable to the open technique, with the added advantages of the laparoscopic approach.

Laparoscopic treatment of hydatid cysts of the liver.

We report for the first time treatment of hydatid cyst of the liver laparoscopically. The patient is a 27-year-old man who presented to our hospital with a 6-week history of recurrent right-upper-quadrant pain with abdominal ultrasound findings compatible with hydatid cyst of the liver. The cyst was approached laparoscopically using the same hydatid asepsis as in open surgery. The cyst was evacuated laparoscopically and marsupialized, and its remaining cavity was packed with omentum. The patient did well postoperatively and was discharged home on the third postoperative day. He had minimal biliary leak that ceased spontaneously on the fifth postoperative day.

Traumatic arteriovenous fistulae: "the Lebanese war experience".

Over a 16-year period from January 1975 to December 1990, 823 patients with 840 vascular injuries were treated at the American University of Beirut Medical Center. Of these, 661 injuries involved peripheral vessels; 26 of which had 31 arteriovenous fistulae (AVF). Most of the AVF (80%) were diagnosed within 1 year from the injury. The most common presenting symptom was a thrill (74%) followed by a pulsating mass (32%). The most commonly affected vessels were the femoral and popliteal arteries. Angiograms were used preoperatively to delineate the extent and location of the fistulae. All patients except three, underwent surgical repair with excellent results with no limb loss. None of the patients developed late complications such as claudication or a vascular deficit in the involved limb. Arteriovenous fistula is a rare but challenging condition following vascular trauma. Its recognition and treatment give excellent results.

Propofol versus thiopentone for induction of anesthesia in patients undergoing outpatient surgery.

Investigation was carried out on 40 females undergoing dilation and curettage or laparoscopy on outpatient basis. All patients were premedicated with pethidine and atropine. In 20 patients, anesthesia was induced with intravenous propofol 2 mg/kg (Group I), and in the other 20 patients thiopentone 4 mg/kg was used (Group II). Prior to induction of anesthesia, 80 mg of lignocaine (4 ml of 2%) was injected intravenously to be followed by the induction agent. No pain followed the injection of propofol or thiopentone and smooth induction of anesthesia was achieved within 60 seconds. Injection of suxamethonium 100 mg and tracheal intubation was then performed and anesthesia was maintained with 66% N2O in O2 supplemented by suxamethonium drip. In the thiopentone group, SBP decreased after induction and tracheal intubation was followed by a significant increase of SBP and HR. In the propofol group, both SBP and HR decreased after induction and tracheal intubation was also followed by an increase of SBP and HR. However, the increase of SBP was less than that observed in the thiopentone group and the increase of HR was not significant when compared to the control value. At the end of surgery and cessation of anesthesia, recovery was scored. After 10 minutes, all patients in the propofol group were awake and initiated conversation while 12 patients of the thiopentone group were still sleepy. The results suggest that propofol may be preferred to thiopentone for induction of anesthesia in outpatient surgery.