Low-dose ropivacaine for supraclavicular brachial plexus block combined with general anesthesia for successful postoperative analgesia: A case series.

BACKGROUND: Ropivacaine, a long-acting local anesthetic agent, has been used for postoperative analgesia in brachial plexus block (BPB) at high doses. However, use of lower doses would reduce the occurrence of adverse effects. METHODS: We applied BPB with low-dose ropivacaine (10 mL of 0.375% ropivacaine) after induction of general anesthesia for surgery of the upper extremities in 62 patients at our hospital. Ropivacaine was administered via a fluoroscopy-guided supraclavicular method. Analgesic effects during surgery, visual analog scale pain scores, skin sensation, muscle strength, and postoperative patient satisfaction indices were evaluated. RESULTS: Fifty-six patients (90.3%) did not require supplemental analgesics during surgery. The remaining six patients were administered fentanyl due to the insufficient analgesic effects of the nerve block. Some adverse effects, including numbness and delayed motor and sensory recovery of the upper extremities, were observed. The mean postoperative patient-evaluated visual satisfaction scale was 94.1. CONCLUSIONS: Our results suggest that low-dose ropivacaine is clinically acceptable for BPB under general anesthesia.

[Spinal epidural hematoma after spinal anesthesia using a 27-gauge spinal needle in a patient with normal coagulation profile].

A 76-year-old man underwent transurethral resection of bladder tumor under spinal anesthesia. Preoperative laboratory date showed normal platelet count (188,000 x microl(-1)) and normal coagulation profile (PT 11.4 sec, APTT 35.1 sec). Lumbar puncture was successfully performed at the L3-4 intervertebral space using a 27-gauge spinal needle with some technical difficulties. Nine hours after the operation, patient suddenly complained of pain from the buttocks to the thighs. Neither motor weakness nor sensory disturbance was found. Therefore conservative therapy was chosen with a diagnosis of transient neurologic symptoms (TNS). However, the subjective symptoms did improve. On the 6th postoperative day, magnetic resonance image (MRI) showed a large epidural hematoma from L1 to L4. On the 13th postoperative day, the subjective symptoms disappeared and MRI on the 17th postoperative day revealed the absence of the hematoma. We should keep in mind that epidural hematoma as well as TNS can occur after spinal anesthesia even with a very fine needle.

[Effect of patient's choice of type of anesthesia or postoperative pain management].

BACKGROUND: Recently, informed consent is important for anesthesia. However, type of anesthesia or of postoperative pain management has been rarely selected by the patient in Japan. We performed a questionnaire survey about the choice of each procedure. METHODS: We studied 104 patients who were to undergo elective surgery between September and December 2005. After the date of the surgery had been scheduled, we informed the patient about each method and offered a choice of method in the anesthetic consultation clinic. On the day before the operation, we obtained the patient's consent. The questionnaire survey was done in post-anesthetic clinic several days after the operation. RESULTS: With regard to anesthesia choice, 36 (70.6%) of the 51 patients chose general anesthesia. Forty-eight patients (94.1%) replied that the anesthesia method choice satisfied them. Forty-eight patients (94.1%) were satisfied with anesthesia. With regard to postoperative pain management choice, 38 (71.7%) of the 53 patients chose epidural anesthesia. Forty-nine patients (92.5%) replied that anesthesia method choice satisfied them. Forty-eight patients (90.6%) were satisfied with anesthesia. CONCLUSIONS: Offering choice of each method led to the patient's understanding and increased the rating of satisfaction with anesthesia. Increase in opportunity for having the anesthetic consultation was effective to obtain better patients understanding about the choice of each procedure.

[Four cases of diplopia following spinal anesthesia].

Many complications after spinal anesthesia have been reported, but diplopia is rare. We had four cases of diplopia in 794 cases of spinal anesthesia in three years at Nara Medical University Hospital. These 4 cases were not characterized by any major factors including gender, age, or anesthetic choice. However, two of them were accompanied with post-spinal headache. Diplopia in three cases improved spontaneously, but one finally required epidural blood patch for the persistent diplopia. Lack of concern regarding the possibility of post-spinal diplopia among medical staffs might be common because this incidence is really rare. However, we need to know the possibility of this neurological sequel after spinal anesthesia. We would like to propose that the informed consent regarding spinal anesthesia should include the possibility of this complication and anesthesiologists should perform intensive neurological examinations after spinal anesthesia concerning post-spinal diplopia.

Positive inotropic effect of nicorandil in adult rats in situ.

PURPOSE: Although the cardiac protective and negative inotropic effects of nicorandil via opening the sarcolemmal or mitochondrial K(ATP) channel and NO-like action are well known, positive inotropic effects of nicorandil in normal hearts have not been reported. The aim of the current study was to investigate how nicorandil affects left ventricular (LV) function of in situ adult rat hearts through the entire cardiovascular system. METHODS: We performed simultaneous and continuous measurements of LV pressure (P) by a catheter-tip micromanometer and LV volume (V) using a conductance catheter. We obtained steady-state LV P-V loops and intermittent curvilinear LV end-systolic pressure-volume relations (ESPVRs), LV end-systolic pressure (ESP(mLVV)), and systolic pressure-volume area (PVA(mLVV)) at midrange LVV (mLVV). We evaluated the effects of nicorandil on LV function by these mechanical indexes sensitively reflecting changes in LV contractility and work capability, preload (end-diastolic volume, EDV), and afterload (effective arterial elastance, Ea). RESULTS: Nicorandil (10 and 20 microg.kg(-1).min(-1)) (blood concentration: 0.53 +/- 0.14 and 1.48 +/- 0.21 microg/ml) largely shifted ESPVR upward and thus significantly increased ESP(0.06), PVA(0.06), stroke volume due to increase in EDV, and ejection fraction without significant changes in Ea and heart rate. In contrast, an NO donor, nitroglycerin (1 microg.kg(-1) . min(-1)), significantly decreased Ea but did not change ESP(0.06), PVA(0.06), and EDV. Furthermore, either a nonselective K(ATP) channel blocker, glybenclamide, or a mitochondrial K(ATP) channel blocker, 5-hydroxydecanoate, abolished these nicorandil-induced positive inotropic actions. CONCLUSION: These results suggest that nicorandil exhibited positive inotropic actions on LV function of in situ hearts in adult rats with resultant increased preload (EDV).

[Patient dissatisfaction with anesthetic care].

BACKGROUND: The evaluation of services by patients is an essential component of quality improvement in anesthesiology. Therefore, it is important to identify the factors for patient dissatisfaction. METHODS: We retrospectively studied 9974 consecutive patients who had received spinal or general anesthesia for elective surgery between 1999 and 2002. Pre-anesthetic, intra-anesthetic and post-anesthetic variables were recorded and patient satisfaction was assessed using direct interviews at the post-anesthetic clinic. Qualitative data on dissatisfaction were obtained by asking patients' reasons for dissatisfaction. RESULTS: 348 of the 8843 respondents (3.9%) had dissatisfaction with anesthesia. The rates of dissatisfaction were higher in women than in men and in spinal anesthesia than in general anesthesia, and were observed mostly in the patients aged from 20 to 39 years. Qualitative data show that the common reasons for dissatisfaction with anesthesia were spinal anesthesia as the most dissatisfactory factor, followed by epidural anesthesia, postoperative pain, vomiting/nausea and memory of tracheal extubation. However, other various factors were associated with dissatisfaction. CONCLUSIONS: It is difficult for anesthesiologists to satisfy all patients, because patients' senses of values were varied. However, we conclude that anesthesiologists can improve the quality of anesthesia by enlightenment of the patient about anesthesia, and moreover, by better peri-anesthetic management for dissatisfactory factors with anesthesia.

[Retrospective analysis of postoperative nausea and vomiting after craniotomy].

BACKGROUND: Postoperative nausea and vomiting are important complications after craniotomy. METHODS: One hundred and seventy eight patients who had undergone brain tumor resection at Nara Medical University were retrospectively divided to one of two groups; with or without PONV within 24 hours postoperatively. Variables compared between the groups include gender, age, weight, height, site of surgery (supratentorial versus infratentorial craniotomy), size of brain tumor, type of anesthesia (inhalation versus intravenous anesthesia with nitrous oxide), intraoperative fentanyl dose, duration of surgery as well as anesthesia, and intraoperative posture. RESULTS: PONV occurred in 87 patients (49%). The incidence of PONV in patients undergoing infratentorial craniotomy was significantly higher than that in patients undergoing supratentorial craniotomy (75% vs 45%, P = 0.0011). There were no significant associations between PONV and other variables analyzed. CONCLUSIONS: These results indicate that the incidence of PONV after brain tumor resection is high and infratentorial surgery is a risk factor for PONV. Strategies for the prevention of PONV after craniotomy are required.

[Effect of teeth protector on dental injuries during general anesthesia].

BACKGROUND: Dental injuries are the most common reason for complaints against anesthetists. The purpose of this study was to investigate the effect of teeth protector on dental injuries during general anesthesia. METHODS: Incidence of dental injuries was evaluated retrospectively in 5,946 consecutive patients between November 1998 and October 2001. All the patients were interviewed directly at a post-anesthetic clinic. RESULTS: Dental injuries were observed in 2.1% of the patients, and the injuries occurred more frequently in the patients undergoing difficult tracheal intubation. The teeth protector used in the present study was made of cellulose aceto-butylate and was produced using eruko-pressed disks molded from own teeth form. One hundred and eighty five patients (3.1%) requested teeth protectors, and none of them had their teeth injured during anesthesia. CONCLUSION: Our results showed that the teeth protector could protect the teeth from dental injuries and increased the satisfaction with anesthesia. Preoperatively anesthesiologists should know the characteristics of patients' teeth and inform the patients of the risk of injury. We conclude that the custom-made protector might be useful and necessary to preserve the teeth from dental injuries during anesthesia.

[Incidence and duration of hoarseness following endotracheal intubation].

The incidence and duration of hoarseness following tracheal intubation with general anesthesia were studied retrospectively from November 1998 to October 2000 in postanesthetic clinic of Nara Medical University. Total number of patients was 3977 and 37.1% of them complained of hoarseness. Most of there patients recovered within three days after surgery but in 4.2% the hoarshness persisted over ten days and in 0.7% persisted over one month after surgery. Most of these persistent hoarseness were considered to have originated from surgical procedures (such cervical, pulmonary, cardioaortic operation, etc.) and those following only tracheal intubation recovered within two months after surgery. The hoarseness decreased the satisfactory level for anesthesia in 1.0% of total patients and 12.8% of patients with persistent hoarseness. We consider that preoperative explanation and postoperative communication by anesthesiologists are important.