Choice of anesthesia and intraoperative monitoring for lower extremity revascularization.

The prevalence of significant coronary artery disease re-enforces the importance of careful preoperative and intraoperative management in patients undergoing lower extremity revascularization. This article presents a practical approach toward the evaluation of anesthetic risk and the proper use of anesthetic agents and monitoring devices to minimize morbidity. The role of general and regional anesthetic agents is discussed, and complications of both techniques are presented.

Premedication with oral and transdermal clonidine provides safe and efficacious postoperative sympatholysis.

We studied 61 patients undergoing elective major non-cardiac surgery in a randomized, double-blind, placebo-control clinical trial to test the hypothesis that the addition of clonidine to a standardized general anesthetic could safely provide postoperative sympatholysis for patients with known or suspected coronary artery disease. Patients were allocated randomly to receive either placebo (n = 31) or clonidine (n = 30). The treatment group received premedication with a transdermal clonidine system (0.2 mg/d) the night prior to surgery, which was left in place for 72 h, and 0.3 mg oral clonidine 60-90 min before surgery. Clonidine reduced enflurane requirements, intraoperative tachycardia, and myocardial ischemia (1/28 clonidine patients vs 5/24 placebo, P = 0.05). However, clonidine decreased heart rates only during the first five postoperative hours; the incidence of postoperative myocardial ischemia (6/28 clonidine vs 5/26 placebo) did not differ between the two groups. Patients who experienced postoperative myocardial ischemia tended to have higher heart rates after surgery. Clonidine significantly reduced the plasma levels of epinephrine (P = 0.009) and norepinephrine (P = 0.026) measured on the first postoperative morning. There were no differences in the need for intravenous fluid therapy or antihypertensive therapy after surgery. The number of hours spent in an intensive care setting and the number of days spent in hospital were not different between the two groups. These results suggest that larger doses of clonidine should be investigated for their ability to decrease postoperative tachycardia and myocardial ischemia.

Value of routine dilation and curettage at the time of interval sterilization.

Four hundred thirty-four patients underwent tubal ligation at the Beth Israel Hospital during a 27-month period. In 272 cases (62.7%), a dilation and curettage was performed as a routine part of the tubal ligation procedure to ensure that luteal phase pregnancy, if present, would be interrupted. Pathology reports on the curettings from all diagnostic dilation and curettages were reviewed. Evidence of pregnancy was found in seven, but only two (0.8%) proved to be of recent nidation. This series demonstrates that routine dilation and curettage at the time of sterilization may not be cost effective or efficient. Hormonal pregnancy testing, combined with accurate menstrual history and timing the tubal sterilization to occur during the follicular phase, if possible, are proposed as alternatives to operative intervention.