Phenol lumbar sympathetic block in diabetic lower limb ischemia.

BACKGROUND: Patients with arteriosclerotic peripheral vascular disease and lower limb ischemia have painful ulceration or incipient gangrene of the lower limb with intractable rest pain. The arteriosclerotic changes may preclude any surgery other than amputation. METHODS: We examined whether chemical sympathectomy could relieve pain, arrest gangrene and postpone amputation, even in diabetic patients. RESULTS: Phenol lumbar sympathectomy was performed on 373 patients, of whom 226 (60.6%) were diabetic. Over 24-120 months of follow-up, 219 patients (58.7%) experienced total relief from pain and healing of gangrenous ulcers, although the treatment was unsuccessful in 154 patients. A favorable result was marked in diabetic patients who had rest pain and in non-diabetic patients who had digital gangrene or digital ulcers. Age and sex did not affect the results but heavy smoking did. CONCLUSION: Phenol sympathectomy should be considered as an alternative to surgical sympathectomy. Furthermore, the technique may be a precursor to and even an alternative to amputation in patients who have diabetes and advanced arteriosclerosis of the lower limb.

[Combined intrapleural and low epidural anesthesia for upper abdominal surgery].

Intrapleural administration of local anesthetics to achieve postoperative analgesia was recently described by Kvalheim and Reiestad. It has been stated that the intrapleural technique provides analgesia, but not surgical anesthesia. However, this method has been used recently for anesthesia during minor surgical procedures. We describe the use of combined, bilateral intrapleural and low epidural anesthesia in a woman with severe impairment of cardiopulmonary function who underwent combined splenectomy and cholecystectomy.

[Delayed post-anoxic encephalopathy].

A case of the rare condition, delayed postanoxic encephalopathy is presented. This condition occurs after an acute hypoxic insult followed by an interval of apparent full recovery, but relapses to various degrees of renewed neurological impairment, coma or even death. Anesthetists should be aware of this entity and establish proper follow-up in patients at risk.

[Benefits of perioperative hemodynamic monitoring in coronary patients].

During 1987-1991, 78 coronary patients were admitted to the intensive care unit (ICU) for noncardiac surgery. 40 were under invasive hemodynamic monitoring and treatment before operation (group A) and 38 were only admitted to the ICU postoperatively, since ICU beds were not available before surgery (group B). The overall incidence of the perioperative complications, ischemic heart, myocardial infarction and cardiac arrhythmias was significantly higher in group B than in group A (p < 0.01). 5% of group A and 11% of group B died in the ICU postoperatively. These data indicate the importance of preoperative hemodynamic and cardiac monitoring and treatment in coronary patients.

Bronchiolitis obliterans--current concepts.

We review current concepts about the clinical manifestations, diagnosis and treatment of patients with bronchiolitis obliterans (BO) with emphasis on clinical/pathological correlations and recent developments. BO is a relatively rare disease, but its incidence is probably higher than generally believed and is continuously rising, partly because of better recognition, but also because of increased exposure to industrial fumes, and its occurrence in lung transplantation. BO is characterized histologically by varying degrees of obliteration of the lumen of the respiratory bronchioles by organizing connective tissue often extending into the alveoli ('proliferative' BO with organizing pneumonia--BOOP) or by more extensive fibrosis and scarring of the more proximal, conductive bronchioles ('constrictive' BO). Diverse clinical conditions have been associated with the development of BO, notably viral and mycoplasma infection, toxic fume exposure and immune reactions in the setting of a collagen vascular disease, drug reaction or organ transplantation. The clinical course and features of BO may vary considerably according to the aetiology, histological pattern and stage of the disease. The most common presentation is that of a progressive dry cough and dyspnea, associated with diffuse patchy interstitial lung infiltrates on chest X-ray. In the more advanced cases, lung function tests show either restrictive or obstructive defects, depending on the extent of alveolar involvement, and hypoxemia without CO2 retention. The diagnosis is often possible on clinical grounds, however, in a seriously ill patient uncertainty should be resolved by tissue diagnosis, preferably by open lung biopsy. Treatment is based on symptomatic therapy. The use of corticosteroids is controversial, but common. Patients with BOOP are exceptional, in that there may be no underlying condition ('idiopathic' BOOP or cryptogenic organizing pneumonia--COP), a restrictive ventilatory defect is usual and the response to corticosteroids often remarkable.

Adult respiratory distress syndrome after radical neck dissection.

The clinical management of an unusual case of postoperative ARDS is reported. A few hours following neck surgery and septic insult, the patient developed unexpected ARDS. Aetiologic and supportive treatment were successfully instituted and after 72 hours of intensive therapy, the patient's clinical status improved. The very short time lapse between the septic insult and appearance of ARDS is emphasized. A brief literature review on aetiology, diagnosis and therapy of sepsis, as well as some pertinent aspects concerning the pathogenesis of ARDS and its linkage to sepsis are presented.

Lidocaine inhalation attenuates the circulatory response to laryngoscopy and endotracheal intubation.

STUDY OBJECTIVE: To evaluate the effect of lidocaine inhalation on the circulatory response to direct laryngoscopy and endotracheal intubation. DESIGN: Prospective, randomized study. SETTING: Operating theater at a public hospital. PATIENTS: Eighty patients (ASA physical status I and II ages 25 to 45 years) scheduled for major abdominal surgery. INTERVENTIONS: In the first stage, 40 patients were randomly assigned to receive inhalation of either lidocaine 40 mg or a 0.9% solution of sodium chloride (placebo). In the second stage, the next 20 consecutive patients received inhalation of lidocaine 120 mg, and another 20 consecutive patients received intravenous (IV) lidocaine 1 mg/kg. MEASUREMENTS AND MAIN RESULTS: Mean arterial pressure rose significantly in the i.v. lidocaine group (21.2 mmHg; p < 0.05), the saline inhalation group (29.2 mmHg; p < 0.05), and the lidocaine 40 mg inhalation group (22.9 mmHg; p < 0.05), but not in the lidocaine 120 mg inhalation group (10.1 mmHg). The heart rate (HR) response to intubation with lidocaine inhalation was dose dependent. In the saline inhalation group, HR increased by 15.6 beats per minute (bpm) (p < 0.05); in the lidocaine 40 mg inhalation group, HR increased by 9.1 bpm (p < 0.05); and in the lidocaine 120 mg inhalation group, HR increased by only 3.1 bpm. CONCLUSION: Inhalation of lidocaine 120 mg prior to induction of anesthesia is an effective, safe, and convenient method to attenuate the circulatory response to laryngoscopy and endotracheal intubation.

Painless intussusception. Giving conservative treatment another chance.

Treatment options for intussusception in children range from reduction by barium enema to surgical intervention. The authors describe a case in which a conservative option--a fifth attempt to reduce an ileocolic intussusception by barium enema, this time using general anesthesia--successfully resolved the problem.