Blood lead levels in children in south central Los Angeles.

We retrospectively reviewed 3 679 pediatric records from King/Drew Medical Center, south central Los Angeles, between 1991 and 1994. Blood lead levels of children were followed to age 18 y. Patients were not referred specifically for lead poisoning. The sample was primarily Latino. Geometric mean blood lead peaked at 6.7 micrograms/dl (0.32 mumol/l) between 2 and 3 y of age. There was a downward secular trend and a seasonal trend. Males had higher lead levels than females. Children who lived in several zipcode areas, in which the lowest family incomes were reported, had higher lead levels. More Latino children had higher lead levels than African American children. Latino children (i.e., 20.2%) who were 1-5 y of age had blood lead levels that were > or = 10 micrograms/dl. Young Latino children in this zone of Los Angeles may be at increased risk for lead exposure.

Effects of drug dose, volume, and concentration on spinal anesthesia with isobaric tetracaine.

BACKGROUND AND OBJECTIVES: Factors governing the spread of local anesthetic in the subarachnoid space have been controversial because of failure to consider the drug related and physical factors. Most studies of isobaric spinal anesthesia in the literature were made using plain bupivacaine which is slightly hypobaric. In this study the effects of drug dose, volume, and concentration were investigated employing isobaric tetracaine (IT). METHODS: One hundred twenty patients were randomly allocated to four groups to receive IT diluted to appropriate concentrations with cerebrospinal fluid. Drugs were administered in lateral position at L3-4 level, with the patient remaining horizontal (supine) during the study. Neural block was assessed by pinprick and the Bromage scale. Except for the factor under investigation, identical techniques were used. RESULTS: Data indicated that volume was the immediate major factor affecting the extent of spread reflected by the significant difference in peak levels between group 1 and group 2 patients. When volume remained constant, increasing dose (mass) concomitantly increased concentration resulting in a faster onset, longer block, and a higher peak level. However, this effect was not prominent and often limited as increasing the dose from 15 mg to 20 mg had no significant effect on the peak levels in group 3 and group 4 patients. CONCLUSIONS: In IT spinal anesthesia, the role of baricity/posture interaction no longer exists, the volume appears the most significant factor by simple bulk displacement or area of contact. Next in significance is the dosage. Increased dose in the same volume implies an increase in concentration that results in faster onset and longer duration and, to a less extent, the peak level.

Translaryngeal guided intubation in an uncooperative patient with maxillofacial injury: case report.

Maxillofacial injuries can produce a wide variety of airway problems. We report the case of a difficult airway situation in an intoxicated and combative patient with maxillofacial injury, for which we resorted to awake translaryngeal guided intubation (TLI).

Adequacy of general anesthesia for cesarean section.

To assess the adequacy of the general anesthesia commonly employed for Cesarean section, we used isolated forearm technique to study 30 parturients (physical status ASA I/II, aged 17-35 yr) scheduled for nonemergent abdominal delivery. Anesthesia was induced with intravenous thiopental (3 mg/kg, 250 mg maximum) and succinylcholine (1.5 mg/kg), and then proceeded with a mixture of 50% N2O, 50% O2, and 0.5% halothane at a flow of 5 L/min and end-tidal CO2 at 40 mm Hg. Paralysis was maintained with a 0.1% succinylcholine infusion. When eyelash reflex disappeared, patients received taped instruction via headphones at 1-min intervals for 10 min. The tapes instructed patients to flex fingers if they were able to hear, to make a fist or squeeze the investigator's hand if they felt pain, to remember six target words, and to respond with specific physical signals during later interviews. Three sets of tapes assigned at random were used in the study. For signs of inadequate anesthesia, other variables such as eye centering, pupil size, sweating, and lacrimation were concomitantly monitored at the time of induction, laryngoscopy/intubation, and skin incision, and then at 1-min intervals for 10 min. Brain activity was also monitored by means of computerized aperiodic analysis of electroencephalogram Lifescan). Patients were interviewed in the postanesthesia recovery room and again 24 h later. At the time of skin incision, 96.7% of patients (29/30) signaled awareness by flexing fingers, 86.7% (26/30) exhibited lacrimation, and 80% (24/30) made a fist or squeezed the investigator's hand, indicating pain perception.(ABSTRACT TRUNCATED AT 250 WORDS)

Prolongation of epidural bupivacaine analgesia with glycerin.

Glycerin has been used as a drug carrier/depot, but never with local anaesthetics. This study was an attempt to use the slow drug release mechanism to prolong the anaesthetic effects of bupivacaine in epidural block. Twenty-seven adults with cancer pain were prospectively selected according to their primary lesions and problems, but their allocation to study groups was randomized. Group I (n = 13), received 5 ml bupivacaine, 0.125% in normal saline via a previous implanted epidural catheter. When the pain returned to its original intensity, the same amount of the same strength anaesthetic dissolved in 50% glycerin was given via the same catheter. Group II (n = 14) received the same solutions, but in the reverse order. Also five patients in each group received plain 50% glycerin prior to administration of the anaesthetic solutions to serve as controls. The pharmacological effects were assessed by the blinded observers. Analgesia produced with glycerin solution was prolonged compared with the saline solution (12.2 vs 7.2 and 11.6 vs 7.4 hr, P < 0.01). The order of giving the solution did not produce any differences. Plan 50% glycerin did not produce analgesic effects. Neither motor blockade nor other adverse effects or complications were observed in either group. It was concluded that 0.125% bupivacaine in 50% glycerin administered epidurally is not neurotoxic. The prolongation of analgesia observed is attributed to the slow release of bupivacaine from the glycerin base which functions as drug depot. In addition to relief of chronic pain, this novel approach may have other clinical applications such as the relief of labour or postoperative pain.

[Epidural administration of bupivacaine in glycerine solution can prolong analgesia].

Glycerine has long been used with phenol as a drug depot in control of intractable pain. However, through our literature review, glycerine has never been used to prolong the pharmacological effects of a local anesthetic, such as bupivacaine. Our study is an attempt to use the same mechanism to further extend the pharmacologic effects of a popular long lasting anesthetic in a commonly used technique. Fifteen adult patients with cancer pain received 0.125% bupivacaine via a chronically implanted epidural catheter. In a blind study of pain control: Group I, consisting of 8 patients, received 5 ml 0.125% bupivacaine in normal saline; group II, consisting of 7 patients, received the same amount of the same strength anesthetic dissolved in 50% glycerine. The pharmacological effect was assessed by evaluation of intensity and duration of sensory as well as motor blockade. Our preliminary experimental experience revealed that significant prolongation (11.8 +/- 2.3 h vs 7.6 +/- 1.8 h, p less than 0.01) of analgesia was observed with the glycerine solution as compared to the saline solution. There was no motor blockade or other adverse effects or complications. This markedly prolonged analgesic effect is attributed to the slow release of the local anesthetic agent from the glycerine base which functions as a drug depot. Other clinical applications of this novel approach in pain relief are currently under investigation.

Translaryngeal guided intubation solved a critical airway problem.

Airway obstruction during the induction of general anesthesia remains a persistent problem in modern anesthesia practice, particularly in obstetric patients. Generally, a careful preoperative airway evaluation uncovers most abnormalities that might make intubation difficult. The planning and preparation for additional intubation equipment facilitate an anticipated difficult intubation. However, situations may arise in which unanticipated airway obstruction occurs requiring prompt management. Although every anesthesia provider is trained to manage such acute airway problems, the provision of a patent airway is not always possible, particularly when repeated attempts at endoscopic or blind intubation have failed, leaving a bloody field that prevents optimal visualization, or when time does not allow to wake up the patient. In this article a difficult airway problem is reported in which translaryngeal guided intubation was lifesaving.

Translaryngeal guided intubation for difficult intubation.

Airway obstruction remains a constant problem in acute care. This is particularly true when there are anatomical or pathological abnormalities, trauma, or when repeated failed attempts at endoscopic or blind intubations have left a bloody field, preventing clear visualization of the vocal cords. Our refinement of translaryngeal guided intubation (TLI) uses a spring guidewire accompanied by a plastic sheath protector. The wire is introduced percutaneously via a cricothyroid puncture and passed cephalad into the oropharynx or nasopharynx and out through the mouth or one of the nostrils. The plastic sheath is slid over the wire into the trachea. A well-lubricated endotracheal tube is then inserted to the desired position using the plastic sheath as a stylet. This technique works very well, and we are convinced that TLI is one of the most effective emergency techniques to secure an airway. It can be performed quickly with inexpensive equipment and is a promising addition to the currently recommended alternatives.