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The effect of chronic anticonvulsant therapy (CAT) on the maintenance and recovery profiles of cisatracurium-induced neuromuscular blockade has not been adequately studied. In this study, we compared the pharmacokinetics and pharmacodynamics of cisatracurium after a prolonged infusion in patients with or without CAT. Thirty patients undergoing intracranial surgery were enrolled in the study: 15 patients under CAT (carbamazepine and phenytoin, Group A) and 15 controls receiving no anticonvulsant therapy (Group C). Anesthesia was standardized and both groups received a bolus of cisatracurium followed by an infusion to maintain a 95% twitch depression. A steady-state was obtained and the infusion was kept constant for 2 additional hours. Neuromuscular blockade was then allowed to spontaneously recover. Blood samples were taken for measurement of cisatracurium plasma concentration during the steady-state period (Cp(ss)95) and at various times during recovery. Demographic and intraoperative data were similar. CAT resulted in faster 25% and 75% recovery of the first twitch. The rate of infusion of cisatracurium needed to maintain a 95% twitch depression at steady-state was 44% faster in Group A (P < 0.001). The clearance of cisatracurium was significantly faster in Group A when compared with Group C (7.12 +/- 1.87 versus 5.72 +/- 0.70 L . kg(-1) . min(-1), P = 0.01). The Cp(ss)95 was also significantly larger in Group A (191 +/- 45 versus 159 +/- 36 ng/mL, P = 0.04). In addition, patients receiving CAT had a 20% increase in the clearance of cisatracurium that, in turn, resulted in a faster recovery of neuromuscular blockade after an infusion of the drug. Also, patients under CAT had a 20% increase in their Cp(ss)95, indicating an increased resistance to the effect of cisatracurium. more...

The fear of producing CO(2) retention and a secondary increase of intracranial pressure (ICP) sometimes precludes the use of sedation for the spontaneously breathing patient in the presence of an intracranial space-occupying lesion. In this study we assessed the effect of moderately deep propofol sedation on the ICP of patients undergoing stereotactic brain tumor biopsy under regional anesthesia. Thirty patients were randomized into 2 groups to receive propofol titrated to a level of 2 on the Observer's Assessment of Alertness/Sedation Scale or no sedation. ICP was measured via the biopsy needle. Preoperative data were similar in both groups. During surgery, patients receiving propofol had a higher arterial Pco(2) (48 +/- 8 mm Hg versus 41 +/- 3 mm Hg; P = 0.005) (95% confidence interval, 43-53 mm Hg and 39-43 mm Hg, respectively), resulting in a lower arterial pH (P = 0.002) than patients in the no-sedation group. The median ICP (95% confidence interval) for both groups was similar-13 mm Hg (8.2-16.2 mm Hg) and 15 mm Hg (8.3-21.7 mm Hg)-for the propofol and no-sedation groups, respectively (P = 0.66). Cerebral perfusion pressure was lower in the propofol group (76 +/- 18 mm Hg versus 89 +/- 18 mm Hg; P = 0.003). Moderately deep propofol sedation does not result in a higher ICP than no sedation in patients undergoing stereotactic brain tumor biopsy. Further studies are needed to assess the effect on ICP of other sedative medications. more...

This retrospective study was designed to assess the quality of postoperative pain control and the facility of transition from epidural to oral analgesia in lung transplant recipients.After institutional review board approval, data were collected from the charts of all patients who underwent lung transplantation at our institution between 1998 and 2002. The study group consisted of the patients for whom an epidural was the first postoperative pain management modality. To serve as a control group we reviewed the charts of 30 patients, randomly selected over the same period, who underwent a thoracotomy for indications other than transplantation and who received postoperative epidural analgesia.Eighty-three patients were available for analysis. Unilateral and bilateral lung transplant recipients had equivalent quality of pain control. However, lung transplant recipients had a lower incidence of adequate pain relief than patients undergoing thoracotomy for other indications (73% vs 87%, p0.05). Lung transplant recipients also had a higher incidence of epidural to oral analgesia transition failure (47% vs 20%, p0.01).This is the first study to assess the quality of postoperative pain control and success of transition from epidural to oral analgesia in lung transplant recipients. Prospective studies are needed to assess the impact of our findings on patients' outcome. more...

We designed this retrospective study to assess the frequency of difficult airway and difficult intubation in patients with spasmodic torticollis and compare it to that of the general population.After Institutional Review Board approval, data were collected from the charts of all the patients with spasmodic torticollis who underwent selective peripheral denervation at our institution between 1988 and 2001. The intubation grade was determined using the Cormack and Lehane laryngoscopic classification. The best laryngeal view was recorded.Data from 342 patients were available for analysis. Fourteen patients had a difficult airway. In two patients, intubation was difficult with three attempts at laryngoscopy in one patient and use of fibreoptic bronchoscopy in the other. Twelve (3.5%) patients presented with laryngoscopic grades of III or IV. The combined prevalence of laryngoscopic view grade III and IV and difficult intubation was 4.4%.This study assesses the frequency of difficult intubation in patients suffering from spasmodic torticollis. When compared to the general population, these patients do not appear to have a higher frequency of difficult airway or difficult intubation. more...

In this prospective study, we assessed the quality, safety, and execution time of supraclavicular block of the brachial plexus using ultrasonic guidance and neurostimulation compared with a supraclavicular technique that used anatomical landmarks and neurostimulation. It was hypothesized that ultrasonic guidance would increase the proportion of successful blocks, decrease block execution time, and reduce the incidence of complications such as pneumothorax and neuropathy. Eighty patients were randomized into two groups of 40, Group US (supraclavicular block guided in real time by a two-dimensional ultrasonic image, with neurostimulator confirmation of correct needle position) and Group NS (supraclavicular block using the subclavian perivascular approach, also with neurostimulator confirmation). Blocks were performed using bupivacaine 0.5% and lidocaine 2% (1:1 vol) with epinephrine 1:200000 as the anesthetic mixture. The onset of motor and sensory block for the musculocutaneous, median, radial, and ulnar nerves was evaluated over a 30 min period. At 30 min 95% of patients in Group US and 85% of patients in Group NS had a partial or complete sensory block of all nerve territories (P = 0.13) and 55% of patients in Group US and 65% of patients in Group NS had a complete block of all nerve territories (P = 0.25). Surgical anesthesia without supplementation was achieved in 85% of patients in Group US and 78% of patients in Group NS (P = 0.28). No patient in Group US and 8% of patients in Group NS required general anesthesia (P = 0.12). The quality of ulnar block was significantly inferior to the quality of block in other nerve territories in Group NS, but not in Group US; the quality of ulnar block was not significantly different between Groups NS and US. The block was performed in an average of 9.8 min in Group NS and 5.0 min in Group US (P = 0.0001). No major complication occurred in either group. We conclude that ultrasound-guided neurostimulator-confirmed supraclavicular block is more rapidly performed and provides a more complete block than supraclavicular block using anatomic landmarks and neurostimulator confirmation.Ultrasound-guided neurostimulator-confirmed supraclavicular block is more rapidly performed and provides a block of better quality than supraclavicular block using anatomic landmarks and neurostimulator confirmation. more...

Sevoflurane (SEVO) provides faster emergence than isoflurane (ISO). This advantage is thought to magnify with increased duration of exposure. In addition, SEVO has several of the characteristics of an ideal neuroanesthetic. We designed a prospective, randomized, double-blinded study to compare the recovery profile of SEVO versus ISO in neurosurgery. Sixty patients undergoing intracranial surgery were enrolled. They were randomized to receive SEVO or ISO in 40% oxygen as part of a balanced anesthetic regimen. The anesthetic concentration (0.5 to 1.0 minimum alveolar anesthetic concentration [MAC]) was adjusted to maintain mean arterial blood pressure within 20% of the preinduction baseline. At the end of the surgery, neuromuscular blockade was reversed, anesthetics were discontinued without prior tapering, and fresh gas flow was increased to 10 L/min. Recovery end-points were measured as the time from closure of the anesthetic vaporizer. Mean MAC-hours were identical in both groups (4.7). Patients in the SEVO group demonstrated a shorter time to emergence (P = 0.02) and for response to command (squeeze hand, P = 0.03; move feet, P = 0.01). Patients in the SEVO group obtained a Glasgow coma scale score of/=10 5 min before patients in the ISO group (P = 0.04). Obtaining an early neurological examination can be critical in neurosurgical patients. The observed difference in emergence between SEVO and ISO could therefore be of clinical importance.The low-solubility anesthetic, sevoflurane, provides faster recovery and postoperative neurological assessment than isoflurane after long-duration (4.7 MAC-h) intracranial surgery. more...

To assess the role of postoperative analgesia on myocardial ischemia after aortic surgery, we compared intravenous patient-controlled analgesia (PCA) with thoracic epidural analgesia (TEA). One hundred twenty-four patients were prospectively randomized to the PCA or TEA group. In the TEA group, a T6-7 or T7-8 epidural catheter was inserted before the induction of general anesthesia. Within 1 h of the end of surgery, analgesia and 24-h two-channel Holter monitoring were begun. Myocardial ischemia was defined as ST segment depressionor = 1 mm, 0.06 s after the J point, and lasting for more than 1 min. In the PCA group, a bolus of morphine, 0.05 mg/kg, was given, followed by 0.02 mg/kg of morphine on demand every 10 min. Bupivacaine 0.125% and fentanyl 10 microg/mL was used in the TEA group. Analgesics were titrated to maintain a visual analog scale scoreor = 3. The overall incidence of myocardial ischemia was 18.4%-18.2% for TEA and 18.6% for PCA (P = not significant). There were no differences between the groups in the total duration of ischemia per patient (22.2 +/- 119.8 min for TEA and 20.5 +/- 99 min for PCA) and the number of episodes per patient (0.69 +/- 2.1 for TEA and 1.2 +/- 4.9 for PCA). Twenty-three patients had an adverse cardiac outcome, although there were no differences between the groups. The postoperative pain control was superior with TEA. In these patients undergoing elective aortic surgery, the use of postoperative TEA did not result in a lower incidence of early myocardial ischemia compared with intravenous PCA with morphine, despite better analgesia with TEA.Postoperative myocardial ischemia is associated with adverse cardiac outcome. Using Holter monitoring after aortic surgery, this study shows that the use of thoracic epidural analgesia with bupivacaine and fentanyl did not result in a lower incidence of myocardial ischemia compared with intravenous patient-controlled analgesia with morphine. more...

Abdominal wall retraction (AWR) was recently proposed as an alternative for CO2 pneumopentoneum. In this study we evaluated the cardiorespiratory effects of AWR during laparoscopic cholecystectomy. Fifteen patients were studied during laparoscopic cholecystectomy using AWR. Monitoring included heart rate (HR). mean arterial pressure (MAP), pulse oxymetry (SpO2), end-tidal CO2 (P1, CO2), minute ventilation, and peak inspiratory pressure (PIP). Using transoesophageal echocardiography, the transgastric short axis view was obtained to derive the end-diastolic area (EDA), the end-systolic area (ESA), and the ejection fraction (EF). These parameters were measured at predetermined periods: I) five minutes after anaesthetic induction, 2) five minutes after AWR insertion, 3) 15 min after AWR insertion, and 4) after the end of surgery. No change in any measured parameter was observed over time in the AWR group except for an increase in MAP (P < 0.05) after AWR insertion. There were no changes in EDA, ESA and EF dunng the study, reflecting stable global cardiac function. In addition, no embolic episodes were observed dunng surgery. Our results demonstrate that the use of gasless abdominal distention for laparoscopic cholecystectomy results in a stable haemodynamic profile in healthy patients without cardiac disease, except for a bnef increase in MAP after the AWR insertion. The advantages of AWR over conventional pneumoperitoneum should be confirmed in higher risk patients in a prospective, randomized study. more...

BACKGROUND The i-gel™ is a supraglottic airway device not requiring inflation of a cuff for lung ventilation. Its design allows for unobstructed passage of a tracheal tube and previous studies have demonstrated a favorable alignment with the glottic inlet. In this prospective randomized study, we compared the success rate of blind tracheal intubation using the i-gel and the laryngeal mask airway (LMA) Fastrach™. METHODS One hundred sixty patients requiring general anesthesia and airway management were randomized to tracheal intubation using the i-gel or the LMA Fastrach. After induction of general anesthesia, the allocated device was inserted and adequate lung ventilation was confirmed. Blind tracheal intubation was then attempted. First attempt and overall tracheal intubation success rates were evaluated and tracheal intubation times were measured. RESULTS Eighty patients were recruited in each study group. Successful tracheal intubation was obtained on the first attempt in 69% of patients with the i-gel and 74% of patients with the LMA Fastrach (95% confidence interval [CI] of difference, -9% to 19%, P = 0.60). The overall intubation success rate was lower using the i-gel than it was using the LMA Fastrach (73% vs 91%, 95% CI of difference, 7% to 31%, P < 0.0001). CONCLUSIONS On first attempts, successful blind tracheal intubation was obtained at comparable rates using the i-gel and the LMA Fastrach. However, when the first attempt was unsuccessful, subsequent attempts through the i-gel did not significantly increase tracheal intubation success rate. The LMA Fastrach yielded a higher overall intubation success rate. more...

In this study, we compared the quality of transitional analgesia provided by bilateral superficial cervical plexus block (SCPB) or morphine following a remifentanil-based anesthesia for infratentorial or occipital craniotomy.In this randomized controlled and double-blind study, 30 patients scheduled for infratentorial or occipital craniotomy were divided randomly into two groups: group morphine (morphine 0.1 mg·kg⁻¹ iv after dural closure and a SCPB performed with 20 mL of 0.9% saline at the end of the surgery) or group block (10 mL of 0.9% saline iv instead of morphine after dural closure and a SCPB performed with 20 mL of a 1:1 mixture of 0.5% bupivacaine and 2% lidocaine at the end of the surgery). Postoperative pain was assessed at one, two, four, eight, 12, 16, and 24 hr using an 11-point (0-10) numerical rating scale (NRS). Analgesia was provided with subcutaneous codeine.Average NRS scores were similar between the two groups at each time interval over the study period. The average scores (with 95% confidence interval) were 3.9 (3.4-4.4) and 4.3 (3.8-4.9) for the block and morphine groups, respectively (P = 0.25). The delay before administration of the first dose of codeine was not statistically different between the two groups: 25 min (5-2,880) vs 21.5 min (5-90), median and range for the block and morphine groups, respectively. The incidence of nausea and vomiting was similar between the two groups.Bilateral superficial cervical plexus block provides transitional analgesia that is clinically equivalent to morphine following remifentanil-based anesthesia in patients undergoing occipital or infratentorial craniotomies. more...

Background In this study, we compared the effect of light sedation with remifentanil versus propofol on intracranial (ICP) and cerebral perfusion pressure (CPP) of patients undergoing stereotactic brain tumor biopsy under regional anesthesia. Methods This was a prospective, open-label, randomized, and controlled study. Forty patients undergoing stereotactic brain tumor biopsy under regional anesthesia were randomized into two groups to receive remifentanil or propofol titrated to a level of four on the modified Assessment of Alertness/Sedation Scale. ICP was measured via the biopsy needle. Results At the targeted level of sedation, the rates of infusion for remifentanil and propofol were, respectively, 4.2 +/- 1.8 microg x kg(-1) x h(-1) and 4.3 +/- 2.5 mg x kg(-1) x h(-1). At the time of ICP measurement, patients in the remifentanil group had a slower respiratory rate (11/min +/- 3 vs 15 per min +/- 3, P = 0.0001) and a higher PCO2 (48.3 +/- 6.2 mm Hg vs 43.1 +/- 5.5 mm Hg, P = 0.009) than patients in the propofol group. The mean was similar for both groups, 19.0 +/- 11.9 mm Hg vs 16.4 +/- 11.1 mm Hg for remifentanil and propofol, respectively (P = 0.48). Higher mean arterial blood pressure in the remifentanil group (101.1 +/- 13.7 mm Hg vs 85.8 +/- 12.7 mm Hg, P = 0.0008) resulted in a higher CPP than the propofol group: 82.0 +/- 19.0 mm Hg vs 69.5 +/- 17.0 +/- 19.0 mm Hg (P = 0.03). Conclusion Light sedation with remifentanil does not result in a higher ICP than propofol in patients undergoing stereotactic brain tumor biopsy. CPP might be better preserved with remifentanil. more...

The purpose of this study was to examine the effects of interpleural bupivacaine on analgesia and ventilatory capacity after cholecystectomy. Forty-two patients undergoing elective cholecystectomy were randomly assigned to two groups: one to receive interpleural administration of bupivacaine-adrenaline mixture (Group 1 = 22 patients) and the other standard administration of intramuscular meperidine (Group 2 = 20 patients) for postoperative pain relief. The intensity of pain was evaluated by a visual analogue scale (VAS) preoperatively as well as at 2, 8, 24 and 48 hr postoperatively. At the same time, FVC and FEV1.0 measurements were obtained for all patients. The group given interpleural bupivacaine had better pain relief with mean VAS of 0.6 +/- 0.9 (mean +/- SD) 1.1 +/- 1.4, 0.6 +/- 0.9 and 0.8 +/- 1.2 compared with 5.2 +/- 2.2, 5.8 +/- 2.7, 5.5 +/- 2.2 and 4.5 +/- 1.8 for patients receiving meperidine (P less than 0.001). The patients in Group 1 also had larger FVC and FEV than those in Group 2: FVC 22 +/- 14.5 per cent vs 32 +/- 15.2 per cent (P less than 0.005), FEV1.0 25 +/- 15.5 vs 38 +/- 14.8 per cent (P less than 0.001) (mean +/- SD). We conclude that the interpleural analgesia can achieve better pain relief with greater ventilatory capacity than a standard analgesic regimen in the first two days after cholecystectomy. more...

This retrospective study was designed to assess the intensity of postoperative pain in relation to the location of craniotomy.After Research Ethics Board approval, data were collected from the charts of all patients who underwent a craniotomy at our institution between January 2004 and December 2005. The severity of post-craniotomy pain was assessed by collecting scores obtained using an 11-point verbal rating scale and calculating the cumulative analgesic requirements for the first 48 hr postoperatively. Data were compared according to the craniotomy location.Data from 299 patients was available for analysis. On average, 76% of patients experienced moderate to severe postoperative pain. Frontal craniotomy was associated with lower pain scores than four of six craniotomy sites analyzed, with 49% of patients reporting mild pain, a significant difference (P0.05) compared with all other groups except for parietal craniotomies. Frontal craniotomy patients also had lower opioid analgesic requirements compared to patients who underwent posterior fossa craniotomy (P0.05). Logistic regression analysis showed that craniotomy location (P0.0001) and age (P = 0.004) were both independent predictors of the intensity of postoperative pain, with lower pain scores as age increased. Postoperative use of steroids, gender and presence of preoperative pain were not statistically linked to postoperative pain intensity. The prevalence of postoperative nausea and vomiting was 56% and it did not vary according to the location of craniotomy.This study shows that the intensity of postoperative pain in neurosurgery is affected by the site of craniotomy. Frontal craniotomy patients experienced the lowest pain scores, and required significantly less opioid than patients undergoing posterior fossa interventions. more...

Le pentobarbital est l’anesthesiant type utilise dans un modele experimental de reductions cycliques de flot (CFR) chez les lapins. Nos observations initiales, en utilisant une technique anesthesique basee sur l’isoflurane, n’ont pas reproduit les observations rapportees precedemment. Par consequent, nous avons compare les effets de ces deux techniques anesthesiques chez le lapin. Un modele de Folts modifie de lesion de l’artere carotide et de stenose a ete utilise. Douze lapins ont pris part au protocole experimental : cinq dans le groupe pentobarbital (P), et sept dans le groupe isoflurane (I). L’artere carotide a ete exposee et le debit reduit par une clampe. Une lesion standardisee a ete faite par clampage de l’artere carotide avec un forceps fin, ce qui a provoque des CFR. Le nombre de CFR ainsi que la duree pendant laquelle ces reductions avaient lieu ont ete enregistres. L’incidence de thrombose a ete comparee dans chaque groupe, tout comme les valeurs hemodynamiques, hematologiques, et le temps de saignement. La valeur de l’hematocrite, la numeration plaquettaire et le temps de saignement ont ete similaires dans les deux groupes. Le nombre moyen et la portee des CFR [groupe P : 9 (4–16); groupe I: 9 (5–14)] ainsi que la duree pendant laquelle les CFR avaient lieu (groupe P : 39 ±17; groupe I: 38 ± 25 min) ont donne des resultats comparables dans les deux groupes. L’incidence de thrombose complete de l’artere carotide a ete similaire dans les deux groupes. La stabilite du modele est de courte duree, mais le nombre de CFR n’est pas affecte par le type d’anesthesie. Nos resultats suggerent que la duree ideale du protocole experimental devrait e tre de 30 a 45 min afin de maximiser le nombre d’animaux developpant des CFR de maniere soutenue. more...

We compared transitional analgesia provided by scalp nerve block (SNB) or morphine after remifentanil-based anesthesia in neurosurgery. Fifty craniotomy patients were randomly divided into two groups: morphine (morphine 0.1 mg x kg(-1) IV after dural closure and an SNB performed with 20 mL of 0.9% saline at the end of surgery) and block (10 mL of 0.9% saline instead of morphine after dural closure and an SNB performed with a 1:1 mixture of bupivacaine 0.5% and lidocaine 2% at the end of surgery). Postoperative pain was assessed at 1, 2, 4, 8, 12, 16, and 24 h using a 10-point numerical rating scale. Analgesia consisted of subcutaneous codeine. Average numerical rating scale scores were similar between the two groups at each time interval. Total codeine dosage was also similar, except at 4 h postoperatively when it was higher in the block group. The delay before administration of the first dose of codeine was not statistically different between groups: 45 min (20-2880) vs 30 min (10-2880), median and range for the block and morphine group, respectively. Postoperative hemodynamics were similar for both groups. The incidence of nausea and vomiting was slightly more frequent in the morphine group, but the occurrence of confusion did not differ between groups. In conclusion, SNB provides a quality of transitional analgesia that is similar to that of morphine with the same postoperative hemodynamic profile. more...

In this prospective study we compared ultrasound-guided (USG) infraclavicular and supraclavicular blocks for performance time and quality of block. We hypothesized that the infraclavicular approach would result in shorter performance times with a quality of block similar to that of the supraclavicular approach. Eighty patients were randomized into two equal groups: Group I (infraclavicular) and Group S (supraclavicular). All blocks were performed using ultrasound visualization with a 7.5-MHz linear probe and neurostimulation. The anesthetic mixture consisted of 0.5 mL/kg of bupivacaine 0.5% and lidocaine hydrocarbonate 2% (1:3 vol.) with epinephrine 1:200,000. Sensory block, motor block, and supplementation rates were evaluated for the musculocutaneous, median, radial, and ulnar nerves. Surgical anesthesia without supplementation was achieved in 80% of patients in group I compared with 87% in Group S (P = 0.39). Supplementation rates were significantly different only for the radial territory: 18% in Group I versus 0% in group S (P = 0.006). Block performance times were not different between groups (4.0 min in Group I versus 4.65 min in Group S; P = 0.43). Technique-related pain scores were not different between groups (I: 2.0; S: 2.0; P = 1.00). We conclude that USG infraclavicular block is at least as rapidly executed as USG supraclavicular block and produces a similar degree of surgical anesthesia without supplementation. more...

The pharmacodynamics of muscle relaxants in patients with oculopharyngeal muscular dystrophy (OPMD) have never been studied. We designed this study to compare the pharmacodynamics of cisatracurium in OPMD patients versus a control group. Forty patients were enrolled: 20 OPMD patients requiring general anesthesia for cricopharyngeal myotomy and 20 age-matched controls undergoing an operation of similar duration and expected blood loss. Anesthesia was standardized, and both groups received a bolus of cisatracurium 0.1 mg/kg. Onset time, time to 10% T1 recovery, and the intervals 10%-25% and 25%-75% were calculated for both groups. A subgroup analysis was performed in patients with a more severe form of OPMD. Demographic and intraoperative data were similar. Onset time was significantly longer in OPMD patients compared with the control group (4.6 +/- 1.5 min versus 3.4 +/- 1.0 min; P = 0.001). There was no difference in recovery times or indices between groups, regardless of the severity of the disease. In conclusion, there was no difference in the duration of a cisatracurium-induced neuromuscular block between OPMD patients and a control group. A delayed onset of action of the drug may occur. more...

Bilateral sixth nerve palsy is a known though uncommon complication following dural puncture. The recommended treatment consists of hydration and alternate monocular occlusion. The value and the timing of an epidural blood patch (EBP) for sixth nerve palsy remains controversial as some authors have demonstrated benefits in performing an EBP early in course of the nerve palsy whereas others have not found any advantage when an EBP was performed later.A 40-yr-old woman developed bilateral sixth nerve palsy ten days after an unintentional dural puncture. An EBP was done within 24 hr after the onset of the symptoms and immediate improvement of the diplopia was noted by the patient and confirmed by an ophthalmologist. Complete resolution of the diplopia occurred 36 days after the dural puncture.Blood patching within 24 hr of the onset of diplopia may be a reasonable treatment for ocular nerve palsy as it relieved the postdural puncture headache and produced partial improvement of the diplopia. more...

UNLABELLED Several pharmacological interventions reduce perioperative stress hormone release during surgery under general anesthesia. Listening to music and therapeutic suggestions were also studied, but mostly in awake patients, and these have a positive effect on postoperative recovery and the need for analgesia. In this study, we evaluated the effect of listening to music under general anesthesia on the neurohormonal response to surgical stress as measured by epinephrine, norepinephrine, cortisol, and adrenocorticotropic hormone (ACTH) blood levels. Thirty female patients scheduled for abdominal gynecological procedures were enrolled and randomly divided into two groups: group NM (no music) and group M (music). In group M, music was played from after the induction of anesthesia until the end of surgery. In the NM group, the patients wore the headphones but no music was played. We established three sample times for hormonal dosage during the procedure and one in the recovery room. Hemodynamic data were recorded at all times, and postoperative consumption of morphine in the first 24 h was noted. There was no group difference at any sample time or in the postoperative period in terms of mean arterial blood pressure, heart rate, isoflurane end-tidal concentration, time of the day at which the surgery was performed, bispectral index (BIS) value, doses of fentanyl, or consumption of postoperative morphine. There was no difference between the two groups with regard to plasmatic levels of norepinephrine, epinephrine, cortisol, or ACTH at any sample time, although the blood level of these hormones significantly increased in each group with surgical stimulation. In conclusion, we could not demonstrate a significant effect of intraoperative music on surgical stress when used under general anesthesia. IMPLICATIONS Listening to music under general anesthesia did not reduce perioperative stress hormone release or opioid consumption in patients undergoing gynecological surgery. more...

The American Society of Anesthesiologists (ASA) has published practice guidelines for the use of perioperative transesophageal echocardiography (TEE) but the role and impact of TEE performed by anesthesiologists outside the cardiac operating room (OR) is still poorly explored. We report our experience in the use of TEE in the noncardiac OR, the recovery room and in the intensive care unit (ICU) in a university hospital, and analyze the impact of TEE on clinical decision making. Two hundred fourteen patients were included and TEE indications were classified prospectively according to the ASA guidelines. The examinations and data sheets were reviewed by two anesthesiologists with advanced training in TEE. For each examination, it was noted if TEE altered the management according to five groups: 1) changing medical therapy; 2) changing surgical therapy; 3) confirmation of a diagnosis; 4)positioning of an intravascular device; and 5) TEE used as a substitute to a pulmonary artery catheter. Eighty-nine (37%), 67 (31%) and 58 (27%) patients had category I, II and III indications. The impact was more significant in category I where TEE altered therapy 60% of the time compared with 31% and 21% for categories II and III (P < 0.001). The most frequent reason for changing management was a modification in medical therapy in 53 instances (45%). Our results confirm a greater impact of TEE performed by anesthesiologists on clinical management for category I compared to category II and III indications in the noncardiac OR surgical setting and in the ICU. more...

Up to 80% of patients report moderate to severe pain after craniotomy. In this study, we assessed the efficacy of scalp block for decreasing postoperative pain in brain surgery. Thirty patients scheduled for supratentorial craniotomy were enrolled. They were randomly divided into two groups: Ropivacaine (scalp block with 20 mL of ropivacaine 0.75%) and Saline (scalp block with 20 mL of saline 0.9%). Anesthesia was standardized. The scalp block was performed after skin closure and before awakening. Postoperative pain was assessed at 4, 8, 12, 16, 20, 24, and 48 h by using a 10-cm visual analog scale. Analgesia was provided with sub- cutaneous codeine as requested by the patient. Average visual analog scale scores were higher in the Saline group as compared with Ropivacaine (3.7 +/- 2.4 vs 2.0 +/- 1.6; P = 0.036). The total dose of codeine did not differ, nor did the duration of time before the first dose of codeine was required in the Ropivacaine (571 +/- 765 min) versus Saline (319 +/- 409 min; P = 0.17) group. In conclusion, we found that postoperative scalp block decreases the severity of pain after craniotomy and that this effect is long lasting, possibly through a preemptive mechanism.Up to 80% of patients report moderate to severe pain after craniotomy. This randomized double-blinded study demonstrated that ropivacaine scalp block decreases the severity of pain after supratentorial craniotomy. more...

UNLABELLED To prevent hypercapnia, voluntary hyperventilation is recommended for patients with increased intracranial pressure before the induction of general anesthesia. We sought to determine whether this maneuver results in a lower PaCO2 than breathing 3 min of oxygen 100% by face mask (preoxygenation) after intubation. Thirty patients requiring general anesthesia were randomly assigned to breathe either 3 min of oxygen 100% by face mask (Group P) or 1 min of oxygen 100% followed by 2 min of voluntary hyperventilation with oxygen 100% (Group H). All patients received a standard rapid-sequence induction of anesthesia followed by a 90-s period of apnea. Patients were then tracheally intubated and mechanically ventilated. Five arterial blood gas samples were taken: with room air, after preoxygenation or hyperventilation, after 60 and 90 s of apnea, and after tracheal intubation. Voluntary hyperventilation decreased PaCO2 before rapid-sequence induction (hyperventilation, 30.0 +/- 3.5 mm Hg versus preoxygenation, 37.9 +/- 5.2 mm Hg; P < 0.0001), but after 60 s of apnea, both groups had similar PaCO2 (hyperventilation, 36.1 +/- 3.3 mm Hg versus preoxygenation, 35.6 +/- 3.4 mm Hg; P = 0.673), and no benefit was found after intubation (hyperventilation, 40.5 +/- 3.9 mm Hg versus preoxygenation, 41.4 +/- 2.7 mm Hg; P = 0.603). We conclude that voluntary hyperventilation before rapid-sequence induction does not provide protection against potential hypercapnia during intubation. IMPLICATIONS Voluntary hyperventilation before anesthesia induction is recommended for patients with increased intracranial pressure to prevent hypercapnia. This randomized, prospective study demonstrated that this maneuver does not result in a lower postintubation PaCO2 than standard preoxygenation. more...

To determine the relative impact of each category-based TEE indication according to the ASA guidelines.In 851 patients undergoing cardiac surgery, TEE clinical indications were classified as category I or II according to the ASA guidelines. Category I indications are patients in which TEE is considered useful and category II are those where TEE is potentially useful but indications are less clear. All TEE examinations were reviewed by two anesthesiologists with advanced training in TEE. For each patient, the clinical impact of TEE in the clinical management was assessed using five criteria: 1) change of medical therapy; 2) change in the surgical procedure; 3) confirmation of a suspected diagnosis; 4) positioning of an intravascular device, and 5) substitute to a pulmonary artery catheter (PAC).TEE had greater utility in category I than in category II indications (15/53 (28%) vs. 110/798 (14%) respectively) (P0.01). The nature of the clinical impact was as follows: modification of medical therapy in 67/125 (53%), modification of planned surgical intervention in 38/125 (30%), confirmation of a diagnosis in 34/125 (27%). The impact on therapy was higher in complex surgical procedures (39%) than in valvular replacement (19%) (P0.01) and coronary artery bypass surgery (10%) (P0.001).Our findings validate the usefulness of the ASA practice guidelines demonstrating a greater impact of TEE on clinical management for category I indications than for category II. TEE also had a greater clinical impact in complex surgical procedures and in valvular replacement. more...

To compare two methods of analysis of regional wall-motion (RWM) using transesophageal echocardiography (TEE).Thirty patients undergoing coronary artery bypass surgery were studied. The transgastric short axis view at the mid-papillary level was recorded before and after cardiopulmonary bypass. All images were reviewed by an anesthesiologist trained in TEE and an echocardiographer. Regional wall motion was graded: 1 normal, 2 hypokinetic, 3 akinetic, and 4 dyskinetic. The left ventricle was evaluated according to the guidelines of the American Society of Echocardiography using 6-segment, and 4-segment models. Agreement between observers (interobservers), and for one observer at two different moments (intraobservers), for grading each segment was defined as RWM abnormality scores within 1 grade. A wall-motion score index (WMSI), which is the sum of individual scores divided by the number of segments visualized, was calculated. A Bland Altman analysis was used to assess interobserver variability.Agreement between observers occurred in 96% and 94% of the examined segments, using 4- and 6-segment models respectively. Intraobserver agreement was 99% and 97% for the 4- and 6-segment models. The mean differences (bias) of the interobserver variability in grading the segments were 0.04 +/- 0.79 and 0 +/- 0.72 using a 4- or 6-segment model. The mean difference of the interobserver variability in WMSI were -0.05 +/- 0.42 and 0.05 +/- 0.37 using a 4- or a 6-segment model.Both methods, using either a 4- or a 6-segment model, result in a high intraobserver and interobserver agreement, and a low interobserver variability. more...

Using transesophageal echocardiography (TEE), 16 patients (ASA physical status I-III), undergoing laparoscopic cholecystectomy, were assessed for the occurrence of episodes of gas embolism and cardiovascular changes related to those emboli. The long-axis four-chamber view was monitored continuously, except for predetermined intervals where the transgastric short-axis view was obtained to derive the end-diastolic area (EDA), the end-systolic area (ESA), and the ejection fraction (EF). In one patient, we monitored the longitudinal view of the superior and the inferior vena cava. The monitoring of the patients also included: heart rate (HR), mean arterial pressure (MAP), arterial saturation by pulse oximetry (Spo2), end-tidal CO2 (ETCO2), minute ventilation (VE), and peak inspiratory pressure (PIP). Embolic events were defined as the appearance of gas bubbles in the right cardiac chambers. We observed gas embolism in 11/16 patients (five during peritoneal insufflation and six during gallbladder dissection). Using the longitudinal view of the superior and inferior vena cava (IVC), we found that these emboli were transmitted through the IVC. No episode of cardiorespiratory instability (decrease in MAP > or = 10 mm Hg, Spo2 < 90%) was observed. There was no significant difference in cardiorespiratory variables between patients who presented gas embolism (n = 11) and patients who did not (n = 5) during the studied period. In this small group of patients, we conclude that gas embolism occurs commonly during laparoscopic cholecystectomy but that these gas emboli cause minimal cardiorespiratory instability. more...

IMPLICATIONS A 68-yr-old man developed a tracheogastric fistula after esophageal resection with gastric interposition. We report the anesthetic management of this patient undergoing tracheal repair and fistula closure. more...

We compared the postoperative epidural analgesia provided by the continuous epidural infusion of bupivacaine supplemented with patient-controlled injection (PCA) of epidural fentanyl with that provided by a continuous infusion of bupivacaine supplemented with a continuous epidural infusion of fentanyl. Our patient population comprised 16 ASA physical status I or II patients undergoing laparotomy with a midline incision under general anesthesia combined with bupivacaine epidural analgesia. Post-operatively, a continuous epidural infusion of bupivacaine (0.1 mg.kg-1.h-1) was combined with epidural fentanyl given by either (a) PCA (15-micrograms bolus with a lockout interval of 12 min, n = 8) or (b) continuous infusion (1 microgram.kg-1.h-1, n = 8). In the case of inadequate pain relief in the latter group, the fentanyl infusion rate was increased by 10 micrograms/h. Analgesia evaluated by a visual analogue pain score and by a verbal pain score was similarly effective in both groups. The sedation score was also similar in both groups. The total dose of epidural fentanyl administered during the first 24 h was significantly lower in the PCA group than in the continuous infusion group (405 +/- 110 micrograms vs 1600 +/- 245 micrograms, P less than 0.001). The dose of fentanyl given during each 4-h interval ranged between 40 and 160 micrograms in the PCA group and 251 and 292 micrograms in the continuous infusion group. Clinically detectable respiratory depression was not observed in either group. In conclusion, epidural administration of 0.1 mg.kg-1.h-1 bupivacaine combined with fentanyl provides effective postoperative analgesia with a total dose of fentanyl required that is lower when fentanyl is administered by epidural PCA rather than by continuous epidural infusion. more...