Pulmonary aspiration of gastric contents after a priming dose of vecuronium.

A case is presented of a 16-year-old girl with ectodermal dysplasia for whom dental surgery under general anaesthesia was planned. Following a priming dose of vecuronium, and immediately after injection of sodium thiopentone (5 mg.kg-1) pulmonary aspiration of gastric contents occurred. It is hypothesized that, because of the rapid speed of onset of neuromuscular blocking agents on the laryngeal muscles, that partial laryngeal paralysis was present at the time of induction of anaesthesia and that this was responsible in part for the episode of pulmonary aspiration.

Post-tonsillectomy infiltration with bupivacaine reduces immediate postoperative pain in children.

Pain management after tonsillectomy in children remains a dilemma for the anaesthetist. A previous study demonstrated that the administration of lidocaine 1% topical spray to the peritonsillar fossae before tracheal extubation provided considerable immediate postoperative pain relief in infants and children. However, the pain relief was of short duration. We were hopeful that the use of bupivacaine would offer more prolonged pain relief because of its pharmacological characteristics. Therefore, this study was designed to compare the effects of bupivacaine 0.5% with 1:200,000 epinephrine administered after tonsillectomy either as topical spray or submucosal infiltration on postoperative pain in children. Forty-three patients aged two to ten years were randomized into three groups after tonsillectomy was performed. Group (1) received 0.5 ml.kg-1 normal saline spray; (2) received 2 mg.kg-1 bupivacaine 0.5% with 1:200,000 epinephrine peritonsillar infiltration in a similar volume to Group 1 and; (3) received 2 mg.kg-1 bupivacaine 0.5% with 1:200,000 epinephrine spray to both tonsillar beds. The patients in each group were compared postoperatively with regard to the quality of pain control using the Objective Pain Score, and their analgesic requirements. Peritonsillar infiltration of bupivacaine provided superior immediate postoperative analgesia as reflected by lower recovery room pain scores (P < 0.05) and opioid requirements (P < 0.01). Ward pain scores and analgesic requirements were similar among groups. Peritonsillar infiltration of bupivacaine 0.5% with 1:200,000 epinephrine provides better post-tonsillectomy pain control in the immediate postoperative period than bupivacaine spray or placebo.

Intraoperative anaphylaxis: an association with latex sensitivity.

Latex products have recently been identified as the cause of severe intraoperative anaphylactic reactions. We have identified a group of pediatric patients who appear to be at increased risk for such reactions. Fifteen patients with either spina bifida or congenital urologic abnormalities experienced 19 intraoperative anaphylactic reactions. All patients had frequent previous exposures to rubber materials since infancy as part of their management and/or investigative procedures. Seven of 15 patients had a previous history of local skin reactions to rubber. Only four patients were atopic. All patients had undergone multiple (two of 26) operative procedures before their reactions, the onset of which ranged from 40 to 290 minutes after induction of anesthesia. The reactions varied in intensity from urticaria to severe cardiorespiratory collapse. All these patients subsequently had positive allergy skin tests and positive RAST to latex antigen. We conclude that this group is at risk when they are exposed to latex intraoperatively as a result of frequent past exposure to these materials. Allergic evaluation for latex allergy may assist in the preoperative evaluation of similar patients. In sensitized patients, appropriate prophylactic measures, particularly the avoidance of latex, is required.

Intraoperative anaphylaxis to latex.

This case report describes intraoperative anaphylaxis occurring in a fourteen-year-old female with spina bifida in which latex surgical gloves were incriminated as the aetiologic agent. The patient was non-atopic but since eight years of age she had developed localized angioedema and urticarial skin reactions on exposure to rubber. She had previously undergone several uneventful surgical procedures. Forty-five minutes following induction of anaesthesia and during laparotomy for elective cholecystectomy she experienced sudden onset of increased airway pressure, oxygen desaturation, tachycardia, profound hypotension and erythema consistent with an anaphylactic reaction. Resuscitation with manual ventilation and oxygen, intravenous fluids and an epinephrine infusion was successful. Subsequent investigations for allergies demonstrated a strongly positive skin prick test and RAST to latex antigen, with negative results to anaesthetic agents, antibiotics and inhalant allergens. During two later operations prophylaxis consisting of diphenhydramine, ranitidine and hydrocortisone appeared to prevent further reactions. Latex should be considered as a cause of life-threatening intraoperative allergic reactions in patients with a history of rubber allergy or frequent exposure to latex products.

Fluid through the epidural needle does not reduce complications of epidural catheter insertion.

Epidural catheter insertion may be associated with blood vessel trauma or nerve root irritation. The purpose of this study was to assess whether the injection of small amounts of fluid through the Tuohy needle prior to catheter insertion reduced the incidence of these and other minor complications. Two hundred patients in labour, requesting epidural analgesia, were randomly assigned to one of three groups: Group I--the catheter was inserted without previous injection of fluid; Group II--3 ml, 1.5 per cent lidocaine hydrochloride was injected through the needle prior to catheter insertion; Group III--3 ml, saline was injected prior to catheter insertion. There were no differences among the groups in the incidence of blood vessel trauma or paraesthesiae. We conclude that there is no advantage in injecting of fluid routinely into the epidural space prior to catheter insertion.

Dissociative anaesthesia for coronary artery bypass surgery using ketamine and midazolam. A case report.

Intravenous anaesthesia with a combination of ketamine (Ketalar) and midazolam (Dormicum) infusions was administered to a 49-year-old patient, with a documented history of opiate allergy, undergoing coronary artery bypass surgery. A ketamine infusion supplemented with indomethacin suppositories was used for postoperative pain control.

Management of a glomus jugulare tumour with internal carotid artery involvement.

A previously healthy 40-year-old female presented for surgical resection of a large glomus jugulare tumour with extensive involvement of the carotid siphon and intracranial extension. Conduct of anaesthesia with specific reference to cerebral protection is discussed. A combination of induced hypothermia, barbiturate therapy, normotension, normocarbia and prior clamping of the distal internal carotid artery was chosen. The role of barbiturates as a therapeutic intervention is debated.

Neurolept anaesthesia using etomidate as the hypnotic agent.

A technique of neurolept anaesthesia using etomidate (Hypnomidate; Janssen) instead of nitrous oxide is described in which a continuous infusion of 1 mg/kg/h is used to supplement droperidol, fentanyl and alcuronium. This totally intravenous technique eliminates theatre pollution, may offer haemodynamic stability and may be of use in patients with raised intracranial pressure. Pain on injection and muscle movements which occur with etomidate administration do not detract from the value of this technique.

Etomidate infusion for resection of phaeochromocytoma. A report of 2 cases.

Anaesthesia in patients undergoing resection of phaeochromocytomas is associated with fluctuations in blood pressure and cardiac dysrhythmias. Two patients in whom an etomidate (Hypnomidate; Janssen Pharmaceutica) infusion was used as a supplement to droperidol, fentanyl, pancuronium, air and oxygen anaesthesia are described. Cardiovascular stability was well maintained; the advantages of this technique are discussed.

Anaesthetic management of a difficult intubation.

Intubation management of a patient with polyostotic fibrous dysplasia is described. The principles in planning for a difficult intubation are discussed.

Painful muscle spasm reversed by magnesium sulphate. A case report.

A 25-year-old paraplegic man who had sustained a T3/T4 vertebral compression fracture 3 years previously presented with severe, painful spasm of the left hamstring muscle group of 2 hours' duration. This spasm produced extreme knee flexion of a degree which held the left foot posterior to the right buttock. An intravenous injection of 2 g magnesium sulphate produced immediate relief. Possible mechanisms of action of magnesium are discussed.

Etomidate infusion for neuro-anaesthesia. A case report.

The successful administration of an etomidate infusion as a supplement to droperidol, fentanyl, muscle relaxant, air and oxygen anaesthesia in an 8-hour neurosurgical procedure is described. The merits of this technique are discussed, with particular emphasis on the conduct of anaesthesia in a patient with raised intracranial pressure.

Haemodynamic monitoring during resection of a phaeochromocytoma. A case report.

A 24-year-old woman underwent resection of a phaeochromocytoma. Invasive haemodynamic monitoring was undertaken. Pre-operative alpha-blockade was not instituted and the blood pressure fluctuated widely. The pulmonary capillary wedge pressure and central venous pressure measurements did not correlate well in this patient. Possible reasons for this discrepancy, the value of the pulmonary artery catheter and the advisability of pre-operative alpha-blockade are discussed.