Sumatriptan: an alternative to epidural blood patch?
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Anesthesia, Epidural↗
Biomedical subjects
F J Mercier
Publications and source records attributed to F J Mercier.
Intra-ocular pressure changes during gynaecological laparoscopy.
Laparoscopic surgery carried out under general anaesthesia is associated with physiological changes, which also determine changes in intra-ocular pressure. We measured intra-ocular pressure at each phase of gynaecological laparoscopy, carried out under propofol-alfentanil-isoflurane general anaesthesia, in young women of ASA 1 status, with no pre-existing eye disease. Measurements were made with a Perkins applanation tonometer. Mean arterial pressure and end-tidal CO2 tension were kept constant throughout the study. Intra-ocular pressure decreased significantly after induction of anaesthesia, remained unchanged after a pneumoperitoneum of up to an intraperitoneal pressure of 15 mmHg had been created, increased significantly with head down tilt, but did not increase significantly above pre-induction values. Adequate depth of anaesthesia compensated for the intra-ocular pressure increase caused by head down position. Plateau airway pressure, considered as reflecting intrathoracic pressure, increased with intraperitoneal pressure elevation. However, such changes did not correlate with intra-ocular pressure changes.
Adult↗
Guinea-pig tracheal responsiveness in vitro following general anaesthesia with halothane.
Halothane and isoflurane induce potent bronchodilation during general anaesthesia and have been used successfully during status asthmaticus. The aim of this study was to determine whether airway hyporesponsiveness was prolonged after halothane administration. Sixteen guinea-pigs were submitted for 2 h to either 1.5% halothane in oxygen or 100% oxygen, and were killed 24 h later to elicit isometric tracheal contractions in organ baths with various agonists. Cumulative concentration-response curves to histamine or to KCl and contractions evoked with acetylcholine 1 mM (4.7 +/- 0.8 vs 4.6 +/- 0.5 g) or carbachol 10 microM in calcium-free buffer (4.3 +/- 0.6 vs 4.4 +/- 0.6 g) exhibited no difference between groups. Moreover, when 4% halothane or 4.6% isoflurane were directly bubbled through the organ baths, a significant decrease (13 +/- 1% and 37 +/- 2%) of maximal contractions evoked with acetylcholine and KCI, respectively, was obtained but these relaxant effects did not persist 30 min after cessation of anaesthetic. These results indicate that, even though halothane induces transient airway hyporesponsiveness in vitro, previous halothane anaesthesia in guinea-pigs does not alter subsequent tracheal responsiveness assessed in vitro. Our findings may explain the transient renewal of bronchospasm reported during intermittent periods off halothane in status asthmaticus.
Anesthesia, General↗
[Spinal analgesia for labor].
Combined spinal epidural (CSE) analgesia for labour is usually performed with sufentanil (or fentanyl) which provides powerful and fast onset pain relief (< or = 5 min). Dose reduction of sufentanil from 10 to 5 micrograms may be recommended and has little influence on the 1.5-2 hours of analgesia usually obtained. This mean duration of action may be prolonged by half an hour with the addition of a low dose of bupivacaine (< or = 2.5 mg). CSE analgesia using this association has an elective indication when labour is advanced (cervical dilation > or = 6 cm) because intrathecal sufentanil alone becomes insufficient at this stage and standard epidural analgesia has the drawback of delayed onset. Motor blockade is also very uncommon during intrathecal analgesia and this benefit partly persists while using the epidural. In contrast, intrathecal analgesia and standard epidural analgesia carry a comparable risk of maternal hypotension. Mild pruritus is the sole side-effect often encountered. The only real concern during intrathecal analgesia is the reliability of the epidural location of the catheter when an emergency Ceasarean section is needed. Major improvement will be to prolong the excellent pain relief provided by intrathecal analgesia throughout the whole labour. This will require prolonging substantially the intrathecal analgesia duration and/ or influencing positively the epidural analgesia used afterwards. However, women prefer CSE technique to standard epidurals because of faster onset, less motor block, and feelings of greater self-control.
Adult↗
Epidural analgesia for labour in a parturient with neurofibromatosis.
The first report of epidural analgesia for labour in a 26-yr-old woman with von Recklinghausen's neurofibromatosis is described. Epidural anaesthesia is often considered as contraindicated because neurofibromas may involve spinal cord and nerve roots. However, general anaesthesia was considered at high risk for this parturient on the basis of her previous medical and surgical history and of physical findings. The present observation suggests that epidural analgesia may be used in such circumstances provided that spinal cord neurofibromas have been ruled out by clinical and CT scan (or magnetic resonance imaging) examination.
Adult↗
Is it possible to improve the shape of right double-lumen endobronchial tubes?
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Bronchi↗
Lack of bronchodilator effect after administration of subanaesthetic concentration of isoflurane in mild asthmatic subjects challenged with methacholine.
Volatile anaesthetics used in high concentrations are potent bronchodilators. The effect of lower subanaesthetic concentrations is less documented, particularly in humans with provoked bronchial obstruction. We have studied seven mild asthmatic subjects twice, 1 week apart, during an asymptomatic period. A provocative test with methacholine was performed to produce a decrease in forced expiratory volume in 1 s (FEV1) of at least 20%. The subjects then inhaled either 100% oxygen or 0.75% isoflurane in oxygen for 8 min, via a face mask. During isoflurane inhalation, the subjects lost consciousness but recovered quickly. There was no significant improvement in FEV1 and maximum expiratory flow at 50% vital capacity (MEF50) recorded 3, 6, 9, 14 and 19 min after the end of isoflurane inhalation compared with time-control values. We conclude that lung function in mild asthmatic subjects challenged with methacholine was not improved after administration of a low subanaesthetic concentration of isoflurane. This may be important during recovery from general anaesthesia.
Adult↗
Nitroglycerin for fetal head entrapment during vaginal breech delivery?
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Breech Presentation↗
[The Univent tube: a substitute to double lumen tubes].
The Univent tube was designed as an alternative to double lumen endotracheal tubes. It is a conventional single lumen tube with an additional small channel within the concave anterior wall portion that houses a movable bronchial blocker used for lung isolation. A thin lumen in the blocker itself allows lung deflation and various ventilatory patterns (oxygen inflow, CPAP, jet-ventilation) in the blocked lung. Main indications for the Univent tube include difficult intubation, risk of aspiration and planned postoperative ventilation. The "blind" insertion of the bronchial balloon carries a high risk of primary malpositioning or secondary displacement that may cause a loss of the lung isolation or even tracheal obstruction. Initial insertion with fiberoptic bronchoscope is therefore required and this device must also be available during the whole period of one lung ventilation. High pressures generated by the bronchial cuff and higher cost than that of double lumen endotracheal tubes are two other factors that limit the use of the Univent tube.
Humans↗
[Doppler preoperative evaluation of the prevalence of functional abnormalities of palmar arches in children].
Thromboembolic events and inadequate palmar collateral circulation are the two main mechanisms of hand ischaemia following radial artery cannulation. The latter cause may be detected in adults with Allen's test, which is difficult to perform and to interpret in children. Therefore we investigated preoperatively in children the permeability of palmar arches with doppler ultrasound, prior to radial artery cannulation. Thirty-five children (20 M/15 F), aged between 6 months and 14 years (mean = 4.2 years) were scheduled for doppler ultrasound study of their palmar arches before undergoing a major neurosurgical procedure. This study was performed with a 8 MHz directional doppler probe according to Marcillon's technique. Blood flow in superficial palmar arch and in pad of the thumb were identified. Alterations in flow caused by compression of the radial artery were noted. Results were expressed in qualitative terms: functional arch (normal doppler), moderately functional or non-functional arch (abnormal doppler). In the latter cases, the artery was not cannulated. An anomaly in one or both palmar arches was seen in 43% of children (95% confidence interval: 25-60%). The incidence was comparable on both sides (right: 34%; left: 31%) with a mean probability of 33% (95% confidence interval: 17-49%). The probability of a controlateral anomaly, when one hand was abnormal, reached 70%, e.g., twice that of the first hand (p < 0.01). This indicates a relatively low incidence of asymmetry (20%) and therefore a high incidence of a bilateral anomaly (23%).(ABSTRACT TRUNCATED AT 250 WORDS)
Adolescent↗
[Accidental subdural extra-arachnoid catheterization during epidural analgesia in obstetrics].
The authors describe a case of accidental catheterization of the subdural extra-arachnoid space during epidural analgesia for labour. The epidural catheter had been inserted at the L3-L4 interspace without any problem. A severe hypotension occurred 90 min after the onset of analgesia. A T4 upper sensory level was associated with a complete motor blockade. Total spinal anaesthesia was suspected but ruled out because of delayed onset of analgesia. Extensive epidural anaesthesia was also eliminated as the local anaesthetic dose (15 mL of bupivacaine 0.125%) was not excessive for this patient. After delivery, a water-soluble contrast medium (10 mL of Omnipaque 180) was injected through the catheter and subsequent radiograph of spine showed subdural spread of the contrast medium. This complication might occur more frequently than usually thought and may be life-threatening. Anaesthetic management is discussed in the case of Caesarean section during labour.
Adult↗
[Unusual obstetrical situations: role of locoregional anesthesia].
Breech or twin delivery is a difficult obstetric situation in which both maternal and neonatal risks are increased and where the incidence of caesarean section and instrumental extraction is high. Epidural anaesthesia may worsen the obstetric situation especially if high doses of local anaesthetics are used resulting in a dense motor blockade. If, on the contrary, effective analgesia is obtained by the epidural injection of low concentrations of local anaesthetics especially with opiates, epidural anaesthesia may increase neither the duration of the second stage nor the incidence of caesarean delivery or forceps extraction and may rather improve neonatal outcome. Extension of the sensory block may be rapid, allowing obstetric intervention while maintaining maternal safety and comfort. For similar reasons and by using low dose techniques, epidural anaesthesia should not be anymore considered contra-indicated in the trial of labor after previous caesarean section.
Adult↗
[Hyperthermia after obstetrical epidural anesthesia].
Unlike epidural anaesthesia for general surgery or caesarean section, épidural analgesia for labour leads to maternal hyperthermia. Its recent demonstration is probably related to the multiple influencing factors: site of measurement, ambient temperature, previous labour duration and dilatation at the time of epidural puncture, and occurrence of shivering. During the first 2 to 5 hours of epidural analgesia, there is a weak--if any--thermic increase. Then, when labour is prolonged (mostly primiparae) a linear increase occurs with time, at a mean rate of 1 degree C per 7 hours. The pathophysiology remains hypothetical: heat loss (sweating and hyperventilation) would be reduced during epidural analgesia and therefore surpassed by the important labour-induced heat production. This hyperthermia has been correlated with foetal tachycardia but never with any infectious process. A potential deleterious effect is still debated and may lead to propose an active cooling for the mother. This hyperthermia must also be recognized to avoid an inadequate obstetrical attitude (antibiotics, extractions).
Adult↗
Survey of regional anesthetic practice among French residents at time of certification.
BACKGROUND AND OBJECTIVES: A survey of anesthesia practice was conducted among French residents in anesthesia at the end of their training. This study was performed mainly to evaluate the residents' experience in peripheral nerve blocks. METHODS: Two short clinical cases were proposed to all French residents during a telephone interview immediately before their certification. The first described the case of a young asthmatic patient admitted for an elbow fracture. The second described an elderly woman with severe aortic stenosis admitted for a supracondylar fracture of the femur. A questionnaire had been prepared and was filled in during the interview. Each resident was asked to answer according to the actual choice he or she would have made. For both cases, when general anesthesia was chosen first, the next question was to discuss which regional anesthesia would be used if general anesthesia had to be discarded. In that way, the practical knowledge about most common peripheral nerve blocks learned during residency was investigated. RESULTS: Of 77 residents registered as being at the end of their residency, 8 were on either sabbatical or maternity leave. Regional anesthesia was the first choice in 78% and 57% of cases for the first and second clinical cases, respectively. The regional anesthetic techniques chosen were axillary block (66%), interscalene block (31%), and intravenous regional anesthesia (3%) for case 1 and combined lumbar plexus and sciatic block (36%), epidural anesthesia (30%), single-shot spinal anesthesia (18%), and continuous spinal anesthesia (16%) for case 2. Throughout the residency of the group, 32 +/- 2 axillary blocks, 12 +/- 2 interscalene blocks (axillary vs interscalene, P < .0001), 21 +/- 3 femoral blocks, and 10 +/- 2 sciatic blocks (femoral vs sciatic, P < .0001) had been performed (mean +/- SEM). They had also performed 2.5 +/- 0.5 continuous spinal anesthesias and 17 +/- 3 intravenous regional anesthesias respectively. Upper extremity blocks were more often used during residency than lower extremity blocks (44 +/- 3 vs 31 +/- 4, P < .01). A peripheral nerve stimulator was routinely used by 83% of residents. CONCLUSION: French residents in anesthesiology at time of certification are better trained for peripheral nerve blocks of the upper extremity than for those of the lower extremity. Axillary plexus and femoral nerve block are the most widely used blocks, probably reflecting the techniques the most mastered among teachers. Finally, the extensive use of a peripheral nerve stimulator by residents is probably the result of the widespread use of this device by teachers in France.
Adult↗