Hepatic infarction in preeclampsia as part of the HELLP syndrome: CT appearance.

We describe the computed tomographic (CT) findings of hepatic infarctions in two preeclamptic pregnant women. These infarcts were part of the HELLP syndrome (hemolysis, elevated liver function tests, and low platelets count). In both cases, CT disclosed features characteristic of multiple nonenhancing, low-attenuation, peripheral lesions with vessels coursing through and a mottled appearance. The recognition of such CT findings in liver disease associated with preeclampsia can establish the correct diagnosis.

Effect of spinal versus general anesthesia on bladder compliance and intraabdominal pressure during transurethral procedures.

STUDY OBJECTIVE: To evaluate the influence of spinal versus general anesthesia on bladder compliance and intraabdominal pressure in elderly males undergoing elective transurethral resection of the prostate. DESIGN: Prospective, randomized, open-label study. SETTING: Teaching hospital. PATIENTS: 21 ASA physical status I, II, and III patients at least 18 years of age, undergoing transurethral surgery. INTERVENTIONS: According to a computer-generated randomization schedule, patients were allocated to one of two groups. In Group Spinal (S), 10 mg of hyperbaric tetracaine was administered intrathecally. In Group General Anesthesia (GA), patients received, fentanyl intravenous (i.v. 1 to 2 micrograms/kg and propofol i.v. 1.0 to 2.0 mg/kg for induction of anesthesia. Thereafter, a laryngeal mask airway was inserted and, with spontaneous ventilation, anesthesia was maintained by administering isoflurane (end-tidal 0.7% to 1.2%) and 70% nitrous oxide (N2O) in oxygen. Intraabdominal pressure and bladder compliance were recorded prior to the induction of anesthesia and immediately before the onset of the surgical procedure. MEASUREMENTS AND MAIN RESULTS: The two groups were demographically comparable. In Group S, mean bladder compliance was significantly (p = 0.003) higher and mean intraabdominal pressure significantly lower (p = 0.007) when compared to baseline preanesthetic values. In Group GA, mean intraabdominal pressure significantly (p = 0.006) decreased when compared to baseline preanesthetic recordings. Following the induction of general anesthesia, a small change in bladder compliance was noted. However, statistical significance was not reached. Data were analyzed and compared using Student's t-test (p < 0.05 was considered statistically significant). CONCLUSION: Both spinal and general anesthesia induced a significant decrease in intraabdominal pressure. While both techniques were associated with an increase in bladder compliance, statistical significance was demonstrated only in the spinal anesthesia treatment group.

The induction, maintenance, and recovery characteristics of spinal versus general anesthesia in elderly patients.

STUDY OBJECTIVE: To compare the induction and recovery profiles of three combinations of general anesthesia when used as an alternative to spinal anesthesia for elderly patients. DESIGN: Randomized, prospective, open-label study. SETTING: Large referral hospital. PATIENTS: 100 [ASA physical status I, II, and III] patients over 60 years of age undergoing brief transurethral surgery. INTERVENTIONS: In Groups Propofol-Propofol (P-P), Propofol-Isoflurane (P-I), and Propofol-Desflurane (P-D), anesthesia was induced with fentanyl (1 to 2 micrograms/kg i.v.) and propofol (1.0 to 2.0 mg/kg i.v.) and maintained with 70% nitrous oxide in oxygen and either a propofol infusion (75 to 150 micrograms/kg/min) or isoflurane (end-tidal 0.7% to 1.2%) or desflurane (end-tidal 1% to 4%), respectively. After induction, a laryngeal mask airway was placed and spontaneous ventilation was maintained. In Group Spinal (S), 1.5 ml 4% lidocaine (60 mg), in an equal volume of 10% dextrose, was administered intrathecally. MEASUREMENTS AND MAIN RESULTS: Induction and recovery characteristics were compared. Induction with propofol was technically easier and significantly (medp < 0.0001) faster (4.6 +/- 1.7 min, 4.7 +/- 2.2 min, and 3.8 +/- 1.4 min for Groups P-P, P-I, and P-D, respectively) than induction of spinal anesthesia (9.3 +/- 3.4 min). During the induction period, mean arterial blood pressure and heart rate were significantly higher in Group S. Emergence, extubation, and orientation times were similar among the general anesthesia treatment groups. In Group S, patient-generated pain scores were lower (p < 0.05) and recovery room admission longer (p < 0.001). Time to return to baseline digit symbol substitution test (DSST) scores was marginally improved in Groups P-P and P-D when compared to Group P-I. Postoperative nausea, sleepiness, anxiety, and coordination were unaffected by the treatment modality. CONCLUSION: General anesthesia with propofol and desflurane facilitates shorter induction and recovery times without adversely affecting patient comfort. Therefore, this technique may be preferable to spinal anesthesia for elderly patients undergoing short transurethral surgical procedures.

Delivery room analgesia: an analysis of maternal satisfaction.

On the first post-partum day, 324 mothers completed a questionnaire designed to assess maternal perception of delivery room experience. Antenatal pain expectation, actual pain severity, analgesia received, as well as maternal satisfaction and choice of analgesia for future deliveries were recorded. Forty-five percent of primiparae and 36% of multiparae reported that they anticipated suffering extreme pain during delivery. The incidence of unbearable pain was similar among patients who received no analgesia or intravenous pethidine but significantly (P<0.0001) higher when compared to epidural analgesia. During the first stage of labour, continuous epidural analgesia was associated with severe or unbearable pain in 51% and 58% of primiparae and multiparae, respectively. The incidence of severe or unbearable pain during the second stage of labour was 43% and 46% for primiparae and multiparae, respectively. Patient satisfaction with epidural analgesia did not correlate with subjective pain scores. Among mothers who received continuous epidural analgesia 70% described their experience as good or excellent and 65.8% indicated that they would request similar pain relief in the future. Despite advances in obstetric analgesia, women anticipate and actually experience severe pain during childbirth. However, due to psychological and cultural factors, as well as possible post-partum euphoria, satisfaction with the delivery room experience is high.

Alternating patient position following the induction of obstetric epidural analgesia does not affect local anaesthetic spread.

To assess the influence of gravity on epidural-induced sensory blockade during the first stage of labour, 60 parturients were recruited to a randomized, controlled, single-blinded study. In all cases an epidural catheter was placed with the patient in the left lateral position. Thereafter, patients were randomized to one of three groups. In group supine (S), the epidural injection was performed in the supine position with a 15-20 degrees right flank elevation and the patient remained supine. In group left (L) patients remained in the left lateral position for 10 min after injection. In group left and right (L+R) patients remained in the left lateral position for 5 min and then assumed the right lateral position for 5 min. Thereafter, in groups L and L+R patients lay supine with a 15-20 degrees right flank elevation. All patients received 50 microg fentanyl in 10 ml of 0.125% bupivacaine. Ten minutes after injection loss of pinprick and temperature sensation were assessed and pain scores measured. Height of sensory deficit 10 min after injection and after maximal blockade were unaffected by patient position. In all cases maximal blockade reached T8 or higher. Time to maximal block was 14.7 +/- 2.3 min, 14.1 +/- 1.6 min and 13.9 +/- 1.5 min for groups L, L+R and S respectively. After maximal blockade, pain scores were significantly (P<0.0001) decreased in all groups, with no differences between them. We conclude that position immediately following local anaesthetic drug administration has little effect on onset and distribution of epidural analgesia.

Anaesthesia for caesarean delivery: low-dose epidural bupivacaine plus fentanyl.

To determine the acceptability of epidural bupivacaine-induced sixth thoracic (T6) sensory blockade and the analgesic efficacy of epidural fentanyl 50 microg, 24 parturients undergoing elective caesarean section were given a test dose of lidocaine 60 mg plus epinephrine followed by 10 ml of either 0.5 % bupivacaine (control group) or 0.5 % bupivacaine plus 50 microg fentanyl (fentanyl group) in a randomized double-blind manner. Fifteen minutes later loss of pinprick sensation was determined. Additional local anaesthetic was titrated to achieve T6 sensory blockade. Intraoperative pain intensity was assessed using a 10 cm visual analogue scale (VAS); total dose of bupivacaine and need for i.v. rescue fentanyl were recorded. The incidence of intraoperative respiratory depression, nausea, vomiting and pruritus were documented. Mean (+/- SD) volume of bupivacaine was 14.1 +/- 3.05 ml versus 13 +/- 1.48 ml for the control and fentanyl groups respectively. The most severe intraoperative VAS for pain was significantly (P=0.023) lower in the fentanyl group (0.4 +/- 0.08 cm) than in the control group (3.1 +/- 0.3 cm). Rescue fentanyl was administered in 40% and 0% of patients in the control and fentanyl groups respectively. The incidence of side-effects was unaffected by treatment group. Apgar scores were similar in the two groups. We conclude that following administration of 10-15 ml 0.5% bupivacaine plus fentanyl 50 microg, T6 sensory blockade is associated with good intraoperative analgesia without obvious maternal or neonatal respiratory depression.

Acute normovolaemic haemodilution decreases postoperative allogeneic blood transfusion after total knee replacement.

We hypothesized that the success of postoperative blood conservation after acute normovolaemic haemodilution (NVHD) is influenced by the extent of intraoperative bleeding and surgical trauma, and the timing of autologous blood transfusion. As total knee replacement is associated with minimal intraoperative but extensive postoperative blood loss, this procedure is ideally suited to acute NVHD. Therefore, to test our hypothesis, 30 patients undergoing elective total knee replacement were enrolled in a prospective, randomized, controlled study. In groups NVHD-2 and NVHD-6, before induction of anaesthesia patients were bled to a target packed cell volume (PCV) of 28-30%, and in the post-anaesthesia care unit autologous blood was transfused over a 2-h period terminating after operation at 2 and 6 h, respectively. In the control group, NVHD was not performed. After operation, platelets, fibrinogen, prothrombin and partial thromboplastin time, and liver function, urea and electrolytes were measured and compared with preoperative baseline values. Significantly (P < 0.024) more allogeneic blood was transfused in the control group (21 u.) compared with either group NVHD-2 (7 u.) or group NVHD-6 (5 u.). In the control group, despite the allogeneic blood transfusion, postoperative PCV decreased until day 4 after operation. Coagulation profile, liver function and urea and electrolytes concentrations were unaffected by the method of treatment. We conclude that for total knee replacement, acute NVHD is an effective blood conservation strategy. However, there was no difference in allogeneic blood administration between the two NVHD groups. Coagulation and liver function, and urea and electrolyte concentrations were unaffected by treatment.

Role of the anesthesiologist in the early diagnosis of life-threatening complications during laparoscopic surgery.

Two cases of massive hemorrhage following blind introduction of laparoscopic instruments are presented. The role of the anesthesiologist in the early diagnosis of potentially life-threatening complications of laparoscopic surgery is discussed.

The antinociceptive effect of epidural lignocaine and fentanyl during lithotripsy.

To determine the antinociceptive effect of combining epidural fentanyl with lignocaine during non-immersion lithotripsy, 56 healthy patients were enrolled into a prospective, randomized, double-blind study. Epidural anaesthesia was induced with either lignocaine 300 mg alone, or lignocaine 300 mg, or 200 mg in combination with fentanyl 100 micrograms. Throughout the procedure analgesia was assessed by comparing the incidence of (a) spontaneous complaints of pain, (b) patients' attempts to withdraw from the painful stimulus, (c) supplemental epidural lignocaine requirements, (d) the haemodynamic response to lithotripsy and (e) the time to first postoperative pain. The patients who received the fentanyl-lignocaine 300 mg combination required no supplemental lignocaine, experienced marginally less intraoperative pain and recorded lower mean arterial blood pressures when compared with lignocaine 300 mg alone. However, when the combination of lignocaine 200 mg and fentanyl 100 micrograms was administered, patients experienced significantly more pain, withdrew from the painful stimulus more often and received more supplemental lignocaine when compared with the other two treatment groups. No difference was found in the time to the first complaint of postoperative pain. Similarly, discharge times were unaffected by treatment modality. We conclude that despite the addition of fentanyl, adequate analgesia during lithotripsy is dependent upon the dose of local anaesthetic administered.

Ketorolac does not decrease postoperative pain in elderly men after transvesical prostatectomy.

PURPOSE: To assess the postoperative analgesic efficacy and morphine-sparing effect of ketorolac in elderly patients. METHODS: Sixty ASA-physical status I to III men, aged 60-88 yr, undergoing transvesical prostatectomy were studied according to a randomized, placebo controlled, double-blind study protocol. A standard general anaesthetic was administered. Thirty minutes before concluding the surgical procedure either ketorolac 60 mg or an equal volume of saline was administered, im. Postoperative pain was assessed hourly for six hours using a 100 mm visual analog score (VAS) and a patient-controlled analgesia (PCA) device. RESULTS: Hourly PCA-demands, actual morphine delivered, and patient generated VAS pain scores were unaffected by the treatment modality. On conclusion of the study the total PCA morphine delivered was 11.9 mg +/- 1.38 and 10.8 mg +/- 1.52 for the saline and ketorolac groups, respectively. CONCLUSION: The intraoperative administration of ketorolac, 60 mg, im, was not associated with postoperative morphinesparing or improved analgesia in this elderly population.

A comparative study of ketorolac and diclofenac on post-laparoscopic cholecystectomy pain.

In a randomized, double-blind, placebo-controlled study designed to assess the post-operative analgesic efficacy and cost-effectiveness of ketorolac and diclofenac 60 ASA I and II patients undergoing laparoscopic cholecystectomy were studied. Prior to concluding the operative procedure, an injection (i.m.) of an equal volume of either saline 3 mL, ketorolac 60 mg, or diclofenac 75 mg was administered. All patients received intravenous morphine via a patient-controlled analgesia device (PCA). Post-operative pain intensity was assessed hourly for 4 h, by recording visual analogue score (VAS) for pain, PCA demands and actual morphine administered. PCA demands (mean +/- SD) were greater in the saline treatment group (115 +/- 90) when compared with both the ketorolac (42 +/- 44) and diclofenac groups (74 +/- 77). Furthermore, the saline treatment group received significantly (P < 0.05) more PCA morphine compared with both the ketorolac and diclofenac groups (12.2 mg +/- 5.0 vs. 8.6 mg +/- 5.2 vs. 8.9 mg +/- 4.8). Improved pain scores were demonstrated in both the ketorolac and diclofenac groups compared with the saline group. PCA demands and post-operative morphine requirements were similar in the ketorolac and diclofenac groups. Diclofenac has the added advantage, in our institution, of being 60% less expensive than ketorolac. We conclude that both ketorolac and diclofenac are effective post-operative analgesic drugs. However, economic considerations may favour diclofenac administration.

Tracheal anaesthesia for transthoracic endoscopic sympathectomy: an alternative to endobronchial anaesthesia.

When using endobronchial anaesthesia for the management of transthoracic endoscopic sympathectomy (TES), excessive insufflation of carbon dioxide into the pleural space may cause haemodynamic instability, hypoxaemia and tension pneumothorax. We prospectively studied an alternative technique using a tracheal tube, i.v. fentanyl, propofol, atracurium and nitrous oxide in 82 consecutive healthy patients (31 male, 51 female; mean age 26.48 (range 14-50) yr, weight 61.26 (33-100)kg.) They were suffering from severe palmar hyperhidrosis and they underwent bilateral TES (mean duration of operation 34.57 (15-90) min). After being placed in a 30-40 degree head-up position, three patients required ephedrine to treat arterial hypotension. A capnograph was used to confirm correct placement of the Verres needle in the pleural space. In two groups of 13 patients undergoing ventilation with an FlO2 of either 0.3 or 0.4, during partial collapse of the operative lung, PaO2 and the PaO2:FlO2 ratio decreased significantly (P < 0.001). TES was unsuccessful in three patients because of pleural adhesions. After operation five patients required chest drains; two for haemothorax and three for pneumothorax. Seventy-seven patients without complications were discharged from hospital within 24 h.

Residual pneumoperitoneum: a cause of postoperative pain after laparoscopic cholecystectomy.

After laparoscopic cholecystectomy, residual gas is inevitably retained in the peritoneal cavity. An active attempt is not always made to remove it. Using a double-blind prospective protocol in 40 healthy patients, we evaluated the effect of residual pneumoperitoneum on post-laparoscopic cholecystectomy pain intensity. On completion of surgery, prior to removal of the surgical instruments, the patients were randomly divided into two groups: in the active aspiration (AA) group an active attempt was made to remove as much gas as possible from the peritoneal cavity, while in the nonactive aspiration (NAA) group no such effort was made. Postoperative pain was assessed hourly over a 4-h period with a visual analog scale (VAS) and a patient-controlled analgesia (PCA) device. During the first postoperative hour, the NAA patients made significantly (P < 0.05) more demands (mean +/- SD) for morphine than those in the AA group (31.3 +/- 26.2 vs 15.3 +/- 15.7) and also received a borderline significantly (P = 0.056) larger dose (mean +/- SD) of PCA morphine (3.9 +/- 1.9 mg vs 2.7 +/- 1.3 mg). The VAS scores (mean +/- SD) over the 4-h study period were similar in both groups, being high during the first postoperative hour (AA = 5.1 +/- 2.1 vs NAA = 6.1 +/- 2.2) and then decreasing. We conclude that residual pneumoperitoneum is a contributing factor in the etiology of postoperative pain after laparoscopic cholecystectomy.

Endoscopic transthoracic sympathectomy in the treatment of primary hyperhidrosis. A review of 290 sympathectomies.

OBJECTIVES: To describe the surgical technique of endoscopic transthoracic sympathectomy for the treatment of palmar hyperhidrosis and to identify associated complications. DESIGN: Prospective clinical study. SETTING: University referral center. PATIENTS: A consecutive series of 150 patients with primary palmar hyperhidrosis. INTERVENTION: The surgical procedure is performed under general anesthesia. A trocar and endoscope are inserted into the chest cavity. The sympathetic chain and the second, third, and fourth ganglia are then identified, cauterized, and cut. After reinflation of the lung, the procedure is repeated on the other side. RESULTS: Two hundred ninety sympathectomies were performed with a 98% success rate. Complications of the procedure included pneumothorax in seven patients (2.4%), hemothorax in three (1.0%), and temporary Horner's syndrome in two (0.7%). Severe postoperative pain during the first 2 to 4 hours required treatment. Of 60 patients who were followed up for 12 months, 50% developed compensatory sweating and 8.3% developed rebound sweating. Hyperhidrosis recurred in three patients. CONCLUSION: Endoscopic transthoracic sympathectomy is an effective form of treatment for palmar primary hyperhidrosis, is associated with a low morbidity, and can be performed as an ambulatory procedure.

Intraoperative anaesthetic management of hypoxaemia during transthoracic endoscopic sympathectomy.

OBJECTIVE: To present our experience and evaluate intraoperative arterial oxygen desaturation during anaesthesia for transthoracic endoscopic sympathectomy (TES). DESIGN: Prospective open study. SETTING: University Hospital in Israel. SUBJECTS: Consecutive series of patients (n = 210), suffering from upper limb hyperhidrosis, anaesthetised for TES. MAIN OUTCOME MEASURES: Peripheral oxygen saturation (SpO2), haemodynamic status, complications, postoperative pain (n = 210) and arterial blood gases (n = 10). RESULTS: 407 TES; 195 bilateral, 17 unilateral. Surgical time range 20-75 minutes. SpO2 decreased below 98% in 58 patients. Sudden hypotension and bradycardia in two patients. The mean PaO2 was significantly (p = 0.03) decreased during two-lung ventilation (TLV), after reinflation of the right lung, compared with TLV after endobronchial intubation. There was no significant difference in mean PaO2 during one-lung ventilation of both lungs. Lowest PaO2 observed during one-lung ventilation was less than 13.3 kPa in three sympathectomies. Postoperative pain, severe on awakening and mainly retrosternal, was relieved with i.v. opiates. CONCLUSION: Controlled ventilation with 100% inspired O2, SpO2 monitoring and one to two gentle manual ventilations when it decreases is the cornerstone of the management of hypoxaemia, a potentially serious complication of TES.

Acute normovolaemic haemodilution and idiopathic scoliosis surgery: effects on homologous blood requirements.

After the introduction of acute normovolaemic haemodilution(NVHD) in our hospital, we prospectively studied 19 patients managed with moderate NVHD (mean haematocrit 0.28, SD 0.02) during idiopathic scoliosis surgery (mean angle 53.2, SD 16.7 degrees) with the Cotrel-Dubousset instrumentation (CDI). Our standard scoliosis anaesthetic technique was used. Intraoperatively, one patient received one unit of homologous blood. Postoperatively, seven patients received ten units of homologous blood. Homologous blood used was reduced by about 83% for this procedure in our institution. In the assessment of fluid and blood requirements we found physical signs reflecting tissue perfusion and oxygen supply more reliable than the estimated blood loss using the suction bottle and swabs. The similar postoperative complications (nine fever, five atelectasis/pneumonia, one urinary infection, one phlebitis), anaesthetic duration (mean 5.21, SD 1.13) hours, hospitalisation (mean 6.67, SD 1.19) days and return to normal activity (mean 8, SD 7.68) weeks indicate that the NVHD patients did just as well as with our previous regimen when only homologous blood was used.

Intertwining and knotting of a guidewire with a central venous catheter.

A guidewire, inserted into a 65-year-old patient with multisystem organ failure through the left subclavian vein, intertwined and knotted with an existing central venous catheter previously inserted via the right subclavian vein. Both the guidewire and catheter were removed without any harm to the patient.

The opioid-sparing effect of diclofenac sodium in outpatient extracorporeal shock wave lithotripsy (ESWL).

STUDY OBJECTIVE: To evaluate the opioid-sparing and analgesic effect of diclofenac sodium in ambulatory nonimmersion extracorporeal shock wave lithotripsy (ESWL). DESIGN: Randomized, double-blind, placebo-controlled study. SETTING: Large referral hospital. PATIENTS: Twenty-seven ASA physical status I and II patients with upper renal tract nephrolithiasis. INTERVENTIONS: ESWL was performed with a sedative-analgesic technique. Diclofenac sodium 75 mg or an equal volume of saline was given intramuscularly 45 minutes prior to the procedure. Fentanyl and midazolam were added to maintain adequate sedation and analgesia. MEASUREMENTS AND MAIN RESULTS: Demographically, both groups were comparable. In the diclofenac sodium group, heart rate was slightly higher, treatment time was shorter, more shock waves were administered (p < 0.02), and less fentanyl was required (p < 0.02). Mean arterial pressure was lower and arterial oxygen saturation by pulse oximeter was higher in the diclofenac sodium group. There were no differences between the groups in voltage, stone size, fragmentation, dose of midazolam administered, or overall assessment by both the doctors and patients. CONCLUSIONS: Patients administered diclofenac sodium received a greater number of shock waves, required less fentanyl, and showed a marginal improvement in hemodynamic stability and oxygenation during ambulatory nonimmersion ESWL.

Anaesthesia for transthoracic endoscopic sympathectomy in the treatment of upper limb hyperhidrosis.

Renewed interest has been shown in transthoracic endoscopic sympathectomy (TES) for the treatment of upper limb hyperhidrosis. We review our experience and discuss the anaesthetic technique and perioperative problems encountered in 58 patients undergoing TES for hyperhidrosis. Patients were monitored for arterial pressure, heart rate, ECG, pulse oximetry (SpO2), end-tidal carbon dioxide concentration, peak inspired airway pressure and skin temperature. General anaesthesia, with a double-lumen endobronchial tube, enabled the lungs to be collapsed alternately, thereby ensuring easy and clear access to the sympathetic chain. Controlled ventilation with 100% inspired oxygen was necessary to obviate hypoxaemia. In two patients, severe hypotension and bradycardia occurred during insufflation of carbon dioxide into the chest cavity. Four patients required underwater drainage of the pleural cavity for treatment of pneumothorax or haemothorax. The success and safety of the procedure depends on a scrupulous anaesthetic technique.