[Palliative sedation in a man with oral cancer; the Royal Dutch Medical Association guidelines not always sufficient]. / Palliatieve sedatie bij een man met mondkanker: KNMG-richtlijn is niet altijd toereikend.

BACKGROUND: Palliative sedation is an effective treatment option in patients with refractory symptoms in the last phase of life. In 2009 the Royal Dutch Medical Association (KNMG) published revised guidelines. The dosage of propofol recommended in these guidelines is, however, based on one single study. CASE DESCRIPTION: A 60-year-old patient with a history of psychiatric disease and alcohol abuse was admitted to the palliative care unit suffering from unbearable pain from a squamous carcinoma of the floor of the oral cavity. Adequate treatment of his symptoms was initially possible, but when his symptoms became refractory we initiated continual sedation. Adequate symptom control was only achieved when propofol was administered in a high dosage of 150 mg/h and levomepromazine administration was reinitiated. CONCLUSION: In our opinion the advised starting dose of propofol is too low, especially in comparison with sedation in regional anaesthesia described in the literature. Furthermore, we advocate that administration of drugs from step 2, midazolam and levomepromazine, is not discontinued when propofol sedation is commenced in step 3.

[Outpatient preoperative examination by the anesthesiologist. I. Fewer procedures and preoperative hospital days]. / Het poliklinische preoperatieve onderzoek door de anesthesioloog. I. Minder verrichtingen en preoperatieve opnamedagen.

OBJECTIVE: To study the effect of the reorganisation of the preoperative screening on the volume of laboratory and function tests, and on preoperative hospital days. SETTING: General Hospital De Weezenlanden, Zwolle, The Netherlands. DESIGN: Retrospective study. METHOD: In The Netherlands the surgeon is responsible for the preoperative screening (anamnesis and general examination). In 1992 the preoperative screening was reorganised and it was carried out in the outpatient department under the responsibility of the anaesthesiologist. Laboratory and function tests were only performed if indicated. Data on 3122 patients, operated in 1991, were compared with the data on 3258 patients from 1992. Multiple regression analysis and chi-square test were used. RESULTS: The proportions of the patients subjected to laboratory tests, ECG or a chest X-ray decreased from 90%, 55%, and 50% respectively in 1991 to 53%, 43% and 10% in 1992 (p < 0.05). Admission on the day of surgery increased from 13% in 1991 to 21% in 1992 (p < 0.01). Clinical preoperative evaluation with admission more than 1 day before surgery, decreased from 5% in 1991 to 4% in 1992 (p = 0.02). The mean duration of the hospital stay before the operation decreased from 0.79 day per patient in 1991 to 0.65 in 1992 (p = 0.02). CONCLUSION: If the preoperative screening is carried out by the anaesthesiologist, all the patients have the opportunity to meet the anaesthesiologist before the operation. The number of preoperative hospital days can be reduced by outpatient preoperative screening. Laboratory and function testing on only if indicated reduces the volume of the laboratory tests, ECGs and chest X-rays.

[Outpatient preoperative examination by the anesthesiologist. II. Patient satisfaction]. / Het poliklinische preoperatieve onderzoek door de anesthesioloog. II. Tevredenheid bij patiënten.

OBJECTIVE: To determine patient satisfaction after the reorganisation of the preoperative screening. SETTING: General Hospital De Weezenlanden, Zwolle, The Netherlands. DESIGN: Retrospective patient interview. METHOD: Before the reorganisation, the preoperative screening was performed clinically under the responsibility of the consultant surgeon. Thereafter it was performed in the outpatient department by the anaesthesiologist. Patients who had had two similar operations within two and a half years, one before and one after the reorganisation, were interviewed at home regarding the different methods of preoperative screening (n = 94). RESULTS: The preoperative screening had a reassuring effect on patients. 72% considered preoperative anaesthesia information important. The number of hospital visits before the operation did not significantly increase after the screening was reorganised. There was little objection to attending the hospital for preoperative screening (12%). Most patients (60%) had no preference for the previous or the present method of screening. Patients who remembered the interview with the anaesthesiologist (56%) preferred the new method (score: 8.2 on a scale 0-10; score of the former method: 7.6; p < 0.01). A larger number of these had the opportunity to ask questions (p = 0.01) and more patients had received attention from the anaesthesiologist (p < 0.01). 75% of the patients had received sufficient preoperative anaesthesia information. 28% of the patients wanted to see the anaesthesiologist again after admission. CONCLUSIONS: Preoperative screening reassures and informs the patient. The patients who could remember the interview with the anaesthesiologist preferred the preoperative screening in the outpatient department. A considerable number of the patients wanted to see the anaesthesiologist again after admission.

Local anaesthetic block therapy of posttraumatic neuralgia of the infraorbital nerve.

The pathogenesis, as well as the results of treatment in 12 patients with neuralgia of the infraorbital nerve are discussed. Patients were treated by means of local anaesthetic nerve blocks, or when this was unsuccessful, by transcutaneous nerve stimulation and or tricyclic antidepressive drugs. In this way, the results were good in previously untreated patients, while they were moderate in patients in whom an attempt to treat with surgery had been carried out earlier. We recommend the use of local anaesthetic nerve blocks as treatment of the first choice.

Delayed air embolism during vascular surgery.

Air embolism occurred in a 25-year-old patient undergoing surgery for reconstruction of the subclavian vein. Air embolism probably occurred twice, the second time at about an hour after closure of the vein. The cause of this delayed air embolism is discussed. We conclude that capnographic monitoring for air embolism is advisable whenever surgery is performed on a patient in the half-sitting position, and that inserting a central venous catheter to facilitate removal of the air in the event of massive air embolism may be wise.

Treatment of venous air embolism with papaverine.

Two cases of venous air embolism are described. One case occurred in a 12-year-old girl operated for ureteroileo-cutaneostomy; the other case occurred in a 44-year-old patient who underwent a hemihepatectomy. The haemodynamic and pulmonary consequences were successfully treated with intravenous papaverine.

Cardiorespiratory effects of the sitting position in neurosurgery.

The hemodynamic and respiratory effects of raising patients from the supine into the sitting position for neurosurgical procedures were investigated in fifteen patients under fentanyl-nitrous oxide anesthesia. The change of position caused a significant decrease in the cardiac output and in the mean arterial blood pressure. An increase in the systemic vascular resistance and in the pulmonary vascular resistance occurred. Half an hour after positioning the patients the mean arterial blood pressure decreased so far that in one third of the patients the cerebral perfusion was threatened. In the sitting position the central venous pressure, measured at right atrium level, became subatmospheric in three patients. The central venous pressure and the capillary wedge pressure decreased, but the pressure gradient between the right and the left atrium reversed in most patients, bearing the risk of paradoxical air embolism. The alveolar-arterial difference in oxygen tension and the intrapulmonary shunt fraction were decreased after raising the patients; the dead space ventilation showed a significant increase.

The capnograph, a reliable non-invasive monitor for the detection of pulmonary embolism of various origin.

The wash-out curve in the capnogram is known to be a sign of pulmonary air embolism. This characteristic pattern is also seen in the case of pulmonary embolism of other nature. Capnographic recordings were studied retrospectively and 22 wash-out curves were found. The quantitative change in end-tidal carbon dioxide concentration was compared with the change in other, circulatory parameters known to change in the case of pulmonary air embolism. There proved to be a quantitative correlation between the decrease in end-tidal carbon dioxide concentration and the change in pulmonary artery pressure, central venous pressure and mean arterial pressure. The capnograph showed to be a reliable monitor for the detection of pulmonary embolism of various origin just like pulmonary artery pressure monitoring is. In cases with concomitant Doppler ultrasound detection, the capnograph showed to be a more reliable monitor for the detection of pulmonary air embolism as is the Doppler ultrasound device.

Pulmonary edema following air embolism.

Venous air embolism is a major hazard during surgical procedures in the sitting position and is known to cause acute pulmonary edema in animal experiments (6, 7, 17). In man some cases of pulmonary edema immediately following air embolism have been described (10, 15, 16). In this case report we present a patient that developed pulmonary edema which became apparent several hours after the occurrence of air embolism.