Distal forearm tourniquet for hand surgery.

To evaluate the usefulness of the tourniquet placed at the distal forearm, 30 patients were operated with the tourniquet set at the distal forearm using nerve-block anaesthesia. Pain during surgery, flexion of the fingers, bloodless field, and general complications during surgery and 18 months thereafter were recorded. The mean time of ischemia was 19.6+/-7.5 (10-50) min. A bloodless field was achieved in all cases, and pain during operation was low. Flexion of the fingers were found in most cases but was reducible and not annoying for the surgeon. There were no serious complications during surgery or at follow-up. The tourniquet placed at the distal forearm is painless, safe, and useful in hand surgery.

Clonidine decreases intraoperative bleeding in middle ear microsurgery.

BACKGROUND: The antihypertensive drug clonidine is a centrally acting alpha2 agonist useful as a premedicant because of its sedative, anxiolytic, and analgesic properties. We examined the effect of clonidine given as an oral preanesthetic medication in producing a bloodless surgical field in patients undergoing middle ear microsurgery. We also evaluated whether the administration of clonidine would alter the reflex cardiovascular response to laryngoscopy and endotracheal intubation, anesthetic requirement, postoperative pain intensity and consumption of analgesics, and pre- and postoperative sedation and anxiety. METHODS: A prospective, randomized, double-blind clinical trial was performed in 40 patients scheduled for elective middle ear surgery under general anesthesia. Twenty-one patients received clonidine (300 microg p.o.) 90 min prior to arrival at the operating theater and 19 received placebo (control group). The hemodynamic endpoint of the anesthetic management was maintenance of hypotension for producing a bloodless surgical field. The desired control of the cardiovascular system was attained with isoflurane (inspired concentration increments of 0.25 vol% up to a maximum of 1.5 vol%)+/-fentanyl (bolus of 1 microg. kg-1)+/-urapidil (bolus of 0.3 mg. kg-1) as needed. Intraoperative bleeding was assessed on a four-point scale from 0=no bleeding to 3=abundant bleeding. RESULTS: There was less bleeding in the clonidine group (mean+/-SEM) than in the control group (0.75+/-0.3 vs 1.1+/-0.4, P<0.05). Patients given clonidine required a mean inspired isoflurane concentration of 0.63+/-0.1 vol% as compared with 1.01+/-0.2 vol% in controls (P<0.05). Fentanyl requirements were also significantly lower (57.10 vs 79.42 microg. kg-1, P<0.05). Four clonidine-treated patients required urapidil to achieve satisfactory hypotension as compared with 11 controls (P<0.05). Clonidine attenuated the associated cardiovascular response following laryngoscopy and intubation, and was more effective than placebo in achieving a satisfactory preoperative sedation and decreasing intensity of postoperative pain. Preoperative anxiety and incidence of adverse events was similar in both groups. CONCLUSION: Premedication with clonidine reduced bleeding in middle ear microsurgery, attenuated hyperdynamic response to tracheal intubation, and reduced isoflurane, fentanyl, and urapidil requirements for controlled hypotension.

Efectos tóxicos de la infusión de morfina subcutánea en paciente con síndrome de vena cava superior / Toxic effects of the infusion of subcutaneos morphine in a patient with upper cava vein syndrome

Introducción: El objetivo del presente caso es describir un cuadro de toxicidad por opiáceos en un paciente con cáncer de pulmón y Síndrome de Vena Cava Superior (SVCS). Los efectos secundarios de la morfina fueron más acentuados en el territorio de drenaje de la vena. Caso clínico: Se presenta el caso clínico de un paciente de 65 años diagnosticado de cáncer de pulmón que desarrolla un SVCS. El enfermo refería dolor severo en región torácica y miembro superior derecho que requirió tratamiento con coadyuvantes, corticoides y opiáceos vía oral. En su evolución precisó la utilización de la vía parenteral, por lo que se le administró una perfusión subcutánea de morfina. A las 12 horas desarrolló un cuadro de enrojecimiento y prurito en hemitórax superior, cuello y cabeza con somnolencia y desorientación. Ante la sospecha de un cuadro de toxicidad local de la morfina, dado que la clínica era localizada, y al comprobar que el lugar de punción fue en el brazo derecho, se retiró la perfusión cediendo la sintomatología. Al reiniciarse la perfusión en el abdomen no volvieron a aparecer los efectos secundarios Conclusiones: En pacientes con Síndrome de Vena Cava Superior que precisen tratamiento con morfina por vía parenteral, debe evitarse el acceso en miembros superiores y tórax, ya que puede aparecer un cuadro de toxicidad local del opiáceo (AU)