Tramadol added to lidocaine for intravenous regional anesthesia.

UNLABELLED: Sixty volunteers, divided into four groups of 15 each, received IV regional anesthesia of the upper limb with 40 mL tramadol 0.25%, sodium chloride 0.9%, lidocaine 0.5%, or 100 mg tramadol-containing lidocaine 0.5%. By using a double-blinded method, we tested the onset and recovery of sensory block at six sites of the forearm and hand as well as onset of complete motor block. The symptoms after deflation of the tourniquet were recorded. The onset and recovery of sensory block and the onset of motor block were similar in the tramadol and saline groups. However, in the Tramadol-Lidocaine Group, the speed of onset of sensory block was faster than in the Lidocaine Group. In the Tramadol and the Tramadol-Lidocaine Groups, the incidence of skin rash and painful or burning sensation at the injection site was increased. We conclude that tramadol 0.25% does not have a local anesthetic effect when used as a sole drug for IV regional anesthesia, but might modify the action of local anesthetic, providing a shorter onset time of sensory block. IMPLICATIONS: Tramadol, a centrally acting analgesic, might have local anesthetic properties, as do some opioid drugs. We demonstrated that 0.25% tramadol solution containing 100 mg tramadol is not effective as a sole drug, but may improve the action of 0.5% lidocaine for intravenous regional anesthesia. The increased incidence of side effects may limit the clinical use of tramadol.

Spinal anesthesia with meperidine. Effects of added alpha-adrenergic agonists: epinephrine versus clonidine.

We determined the effects of intrathecally administered epinephrine and clonidine on the duration and quality of a meperidine spinal block. Forty-five patients scheduled for orthopedic surgery, divided into three groups, received spinal anesthesia with 1 mg/kg 5% meperidine, alone or with 200 microg epinephrine or 2 microg/kg clonidine. Using a double-blind method, the onset, extension, and duration of sensory block (to pinprick) and the duration and degree of motor block (Bromage scale) were assessed. Hemodynamic responses, duration of postoperative analgesia, degree of sedation, and occurrence of side effects were also recorded. The addition of epinephrine to the meperidine solution prolonged the sensory block (P<0.01) but did not affect its onset or extent. A similar potentiating effect was demonstrated for clonidine (P<0.001). The duration and degree of motor block were increased by addition of both epinephrine and clonidine. A tendency toward bradycardia and a decrease of mean arterial pressure was potentiated by clonidine but not by the epinephrine. Only the addition of clonidine prolonged the postoperative analgesia (P<0.001), but was associated with an increased sedation score. The incidence of other side effects did not differ between the groups. We conclude that coadministration of epinephrine or clonidine with meperidine enhances the duration and degree of spinal anesthesia and that adding clonidine prolongs the duration of postoperative analgesia.

Intravenous regional anesthesia with meperidine.

Forty-five ASA physical status I volunteers, divided in three groups of 15 each, received intravenous regional anesthesia (IVRA) of the upper limb with 40 mL meperidine 0.25%, lidocaine 0.5%, or 0.9% sodium chloride (isolated ischemia) by random allocation. Using a double-blind method, the onset and recovery of sensory block was tested at six sites of the forearm and hand. The onset of complete motor block was also assessed. The symptoms after deflation of the tourniquet were recorded. The onset of block, as determined by pin-prick touch, and cold was significantly faster in the meperidine group (P < 0.001) than in the saline group, but also slower (P < 0.001) than in the lidocaine group. After the tourniquet was deflated, recovery occurred in reverse order. A complete motor block was noted in all volunteers from the meperidine and lidocaine groups, but in only 11 cases from the 0.9% sodium chloride group (P < 0.01). In the meperidine group, motor block developed concomitantly or prior to sensory block. There was a significant increase in the incidence of dizziness, nausea, and pain at the injection site in the meperidine group in comparison with the lidocaine group. We conclude that meperidine has local anesthetic action on the peripheral nerve in vivo, but that its single use for IVRA should be a second choice for patients allergic to local anesthetics.

The effects of propofol on laryngeal reactivity and the haemodynamic response to laryngeal mask insertion.

The ease of the insertion of laryngeal mask and the haemodynamic response were assessed 2 min after induction of anaesthesia with either propofol 2.5 mg kg-1 or thiopentone 4.0 mg kg-1 in 38 ASA I premedicated patients. The inserting conditions scored as excellent, good, poor and unable to insert were significantly better with propofol than with thiopentone (P < 0.001). Insertion of the laryngeal mask was followed by a transient but significant increase in both systolic (P < 0.05) and diastolic (P < 0.01) arterial pressure in the thiopentone group; there was no comparable response in the propofol group. The heart rate varied little from baseline in both groups.

[Late reinterventions after the surgical treatment of gastric and duodenal ulcer]. / Reinterventii tardive dupa tratamentul chirurgical al ulcerului gastric si duodenal.

A number of 87 reinterventions performed during a 5-year-period for late complications of the gastric and duodenal ulcer surgery are analysed. In most of them (64 cases), the cause of the reintervention was a postoperative ulcer. A long afferent loop (6 cases), the dumping syndrome (4 cases), the stenosis of the anastomosis opening (6 cases) and the primitive neoplasm of the gastric stump (7 cases) represented other causes of reintervention. The immediate postoperative results were very good and good in 69 cases. The risks related to the specific character of this surgery materialized themselves in 14 postoperative complications (anastomotic fistulas, haemorrhages from the anastomosis, stress ulcers etc.), which required iterative operations; the postoperative death rate attained 3.4%. The analysis of these postgastrectomy syndromes is an opportunity to discuss about the failure factors in the surgery of the gastric and duodenal ulcer, the possibilities of exploration and the principles which should guide the reparative therapy.

Nonsurgical control of upper gastrointestinal hemorrhage in old age patients: intragastric norepinephrine and endoscopic alcoholization of lesions.

Of 28 consecutive patients over 64 years old, in whom endoscopy revealed gastro-duodenal ulcers with signs of recent hemorrhage (active bleeding, non-bleeding vessel or adherent clot), 14 were randomly assigned to receive endoscopic alcoholization of the lesions preceded by intragastric instillation of norepinephrine, while as controls 14 received antacids. After the applied treatment the bleeding stopped in all cases (100%) in the study group and one patient died (7.1%) after hemostasis was achieved. In the control group bleeding stopped in 12 patients (85.7%). Two patients continued to bleed and needed emergency surgery. Another patient had a major rebleed successfully treated by alcoholization. There were 4 deaths (28%): 2 patients died postoperatively and the other 2 from acute porphyria and bronchopneumonia respectively. The transfusion requirements after the entry into trial were significantly lower in the study group compared to controls (mean no. of blood units 0.79 vs. 1.71). No complications were seen with the treatment applied. These results suggest that endoscopic alcoholization of the lesions preceded by intragastric instillation of norepinephrine is an effective and safe emergency therapy for bleeding from peptic ulcers in old age patients.

[The effect of fentanyl as an adjuvant to etomidate and thiopental on the hemodynamic response to the induction of anesthesia and endotracheal intubation]. / Efectul fentanylului ca adjuvant al etomidatului si tiopentalului asupra raspunsului hemodinamic la inductia anesteziei si intubatia endotraheala.

The hemodynamic modifications during anesthesia induction with etomidat or thiopentalum, with and without pretreatment with fentanyl, were studied in 60 ASA I-II patients. The patients were randomly divided into six subgroups, as a function of the induction agent (etomidat, 0.15 mg/kg, or thiopentalum, 3 mg/kg) and of the pretreatment used (fentanyl, 5 micrograms/kg, or 0.9% 1 ml/kg saline solution). Systolic, diastolic ATs and pulse were followed and measured during induction and after tracheal intubation. During induction the presence or absence of the thoracic rigidity, after fentanyl administration, and also the appearance of myoclonias and of local pain after etomidat injection were noted. Measurement of hemodynamic constants showed, in the control subgroups unprotected by fentanyl, that AT and pulse frequency increase following laryngoscopy and intubation irrespective of the induction agent used. Association of thiopentalum with fentanyl influenced partially tachycardia and postintubation hypertension. Administration of 5 micrograms/kg fentanyl prevented the SAT and pulse modifications but not the DAT variation. Association of 10 micrograms/kg fentanyl ensured a complete protective effect versus the tracheal intubation but, it led, first, to a SAT decrease by intensification of the myocardial depressing effect of the barbiturate. On the other hand, use of fentanyl as induction adjuvant with etomidat ensured the blockage of the pressure response to intubation, with hemodynamic stability during anesthesia induction, irrespective of the dose of fentanyl injected. Thoracic rigidity and the side effects generated by etomidate were absent.

[Emergency operations in colorectal cancer]. / Operatii de urgenta în cancerul recto-colonic.

In a group of 161 patients subjected to emergency surgery of rectocolonic cancers with occlusive (111 cases), hemorrhagic (39 cases) or perforating (11 cases) complications, the authors analyze the immediate therapeutic results, as a function of the complication form and the surgical method used in emergency (primary colectomy, serial surgeries, palliative surgeries). Emergency colectomy (55 cases) performed deliberately in strictly selected cases or as the unique possible choice, was followed by immediate good results (the lowest rate of surgical morbidity and mortality) in comparison with the serial surgeries (cumulative morbidity and mortality). The paper discusses the indications of the proximal colectomy and of Hartman's surgery in primary emergency colectomies. Serial surgeries (secondary colectomy--30 cases) are mainly indicated in the complicated cancers of the left colon, in the patients with resectable tumours, but with critical biological state or with insufficiently prepared colon. Palliative surgeries (colostomies, internal derivations) used in patients with nonresectable tumours were followed by the highest surgical mortality, a consequence of the biological substrate weakened by disease and complications. The data reported show the necessity of a selective tactical behaviour in the emergency surgery of rectocolonic cancer and plead for the primary urgent colectomy in the patients meeting certain general and local conditions. Likewise, they point to the importance of discovering rectocolonic cancer in an early stage, before the appearance of complications requiring the emergency surgery.

[Hemodynamic reaction in the ultrarapid induction and protection realized with fentanyl]. / Reactia hemodinamica din inductia ultrarapida si protectia relizata de fentanyl.

The hemodynamic response caused by the orthotracheal intubation and also the fentanyl-induced protection were determined in the patients with ultrarapid anesthetic induction. 60 patients were randomly distributed in 3 groups, each of 30 patients: group I, control, with sequential induction, group II, with ultrarapid induction, and group III with ultrarapid induction protected by fentanyl administration. In the patients in the groups II and III the hydrocortisone in the blood, taken 1 minute before induction and 3 minutes after intubation was dosed radioimmunologically. Measurement of the hemodynamic constants showed the increase of the systolic and diastolic AT, and of the pulse during laryngoscopy and in the first two minutes after intubation in all the patients investigated. The hemodynamic response was stronger in the lot with rapid induction, with important differences in comparison with the group with sequential induction. In the IIIrd group, the previous injection with fentanyl, 5 mcg/kg led to a less intense hemodynamic response to laryngoscopy and intubation, close to that of the control group. Likewise, the injection of the anesthetic was followed by an important decrease in the plasmatic hydrocortisone in comparison with the preinduction values.

Cortical blindness after subclavian vein catheterization.

The occurrence of air embolism with neurologic complications during the insertion of central venous catheters is well known, but the development of a cortical blindness has not been stress. The case of a woman patient is described, who, after the puncturing of the subclavian vein, developed a state of confusion and transient left hemiplegia, followed by the loss of sight. Blindness was associated with normal pupilary light reflexes and no observable changes in the fundi, features identifying it as cortical. Possible pathogenetic mechanisms are discussed.