Biomedical subjects
Publications and source records attributed to R Jedeikin.
Although rare, a congenital direct fistula connection between the proximal right pulmonary artery and the left atrium can present as cyanosis in the newborn. We report the first case in which catheter-based coil closure of such a fistula in a neonate resulted in rapid clinical improvement, obviating the need for surgical repair.
IMPLICATIONS: We report a case of spinal anesthesia in an infant with nemaline myopathy. Spinal anesthesia was administered to preempt the potential problems of difficult tracheal intubation and prolonged mechanical ventilation secondary to muscle weakness after the use of IV anesthetics in this patient.
The authors hypothesize that palmar hyperhidrosis is a systemic manifestation of abnormal sudomotor function; consequently, thoracoscopic sympathectomy to alleviate symptoms in the hands may result in heat dissipation because sweating is transferred to other sites. To investigate this phenomenon and to determine whether it adversely affects patient satisfaction, a standard questionnaire was administered to 626 patients who underwent sympathectomy at a university-associated public hospital between 1991 and 1998; only patients treated at least 6 months before questionnaire distribution were included in the study. Replies were received from 336 (53.7%) individuals. The surveyed patients underwent bilateral T2, T3 (palmar sweating), or T3, T4 (axillary sweating) sympathectomy by a standard video-assisted transthoracic technique. Main outcome measures included the incidence of dry hands, compensatory sweating, chest pain, upper-limb muscle weakness, shortness of breath, and gustatory phenomena; in addition, patient perception of the success of the surgical procedure was assessed. After sympathectomy, 97.3% (P < 0.0001) and 29.2% (P < 0.001) of patients reported significant improvement in palmar hyperhidrosis and axillary sweating, respectively. Postsurgery, severe compensatory sweating was experienced in 90% of patients (P < 0.0001). The sites of compensatory sweating were the back (75%), abdomen (51%), feet (23%), groin and thigh (13%), chest (13%), and axillae (8%). Transient whole-body sweating for no apparent reason was experienced in 30% of patients. Thirty-seven patients (11%) regretted having undergone the surgical procedure. In contrast, 25% and 64% of patients were either satisfied or very satisfied with the outcome of the procedure. From the survey results, the authors conclude that palmar hyperhidrosis is a systemic manifestation of abnormal sudomotor function and that thoracic sympathectomy may alleviate symptoms in a large proportion of patients. However, for some individuals, compensatory sweating may prove to be an equally troublesome handicap. Because the occurrence of severe compensatory sweating is unpredictable, a reversible sympathectomy may be desirable.
STUDY OBJECTIVE: To assess the therapeutic benefits of repeated epidural local anesthetic administration on pain perception and straight leg raise (SLR) in patients suffering from chronic low back pain. DESIGN: Prospective, randomized, controlled, single-blind study protocol. PATIENTS: 50 ASA physical status I, II, and III patients at least 18 years of age, who had previously undergone spine surgery. INTERVENTIONS: All participants were admitted to hospital for the 5-day duration of the study. Following epidural catheterization, fluoroscopy was performed to verify correct placement of the epidural catheter. On the first study day, all patients received depomedrol 80 mg, in 10-ml 1% lidocaine, epidurally. Thereafter, patients were randomized into two equal groups. In Group Bupivacaine (B) 10-ml 0.125% bupivacaine was administered. In Group Saline (S), an equal volume of saline was administered. Epidural injections were performed twice daily (09H00 and 14H00) for 4 days. Sympathetic blockade was confirmed by the presence of peripheral vasodilatation. Sensory blockade was assessed using loss of pin prick and temperature sensation. SLR as well as patient-generated 100-mm visual analog score (VAS) for pain were performed prior to each injection, at 15 minutes after injection, and hourly for 2 hours thereafter. Similar parameters were measured 1 week, 1 month, and 3 months after discharge. MEASUREMENTS AND MAIN RESULTS: 46 patients completed the study. VAS for pain was marginally lower in Group B. However, statistical significance was not demonstrated. During the hospitalization period, the SLR in both study groups significantly (0.008) improved with time. However, no difference between the groups was demonstrated. In both groups, 1 week, 1 month, and 3 months after discharge, the SLR was comparable to prestudy recordings. In Group B, at 1 week, 1 month, and 3 months after discharge, patient-generated VAS for pain were significantly (p = 0.002) higher when compared to pain scores at the time of patient discharge.
STUDY OBJECTIVE: To evaluate the influence of spinal versus general anesthesia on bladder compliance and intraabdominal pressure in elderly males undergoing elective transurethral resection of the prostate. DESIGN: Prospective, randomized, open-label study. SETTING: Teaching hospital. PATIENTS: 21 ASA physical status I, II, and III patients at least 18 years of age, undergoing transurethral surgery. INTERVENTIONS: According to a computer-generated randomization schedule, patients were allocated to one of two groups. In Group Spinal (S), 10 mg of hyperbaric tetracaine was administered intrathecally. In Group General Anesthesia (GA), patients received, fentanyl intravenous (i.v. 1 to 2 micrograms/kg and propofol i.v. 1.0 to 2.0 mg/kg for induction of anesthesia. Thereafter, a laryngeal mask airway was inserted and, with spontaneous ventilation, anesthesia was maintained by administering isoflurane (end-tidal 0.7% to 1.2%) and 70% nitrous oxide (N2O) in oxygen. Intraabdominal pressure and bladder compliance were recorded prior to the induction of anesthesia and immediately before the onset of the surgical procedure. MEASUREMENTS AND MAIN RESULTS: The two groups were demographically comparable. In Group S, mean bladder compliance was significantly (p = 0.003) higher and mean intraabdominal pressure significantly lower (p = 0.007) when compared to baseline preanesthetic values. In Group GA, mean intraabdominal pressure significantly (p = 0.006) decreased when compared to baseline preanesthetic recordings. Following the induction of general anesthesia, a small change in bladder compliance was noted. However, statistical significance was not reached. Data were analyzed and compared using Student's t-test (p < 0.05 was considered statistically significant). CONCLUSION: Both spinal and general anesthesia induced a significant decrease in intraabdominal pressure. While both techniques were associated with an increase in bladder compliance, statistical significance was demonstrated only in the spinal anesthesia treatment group.
STUDY OBJECTIVE: To assess mental and psychomotor recovery following induction of anesthesia with thiopental or propofol in elderly patients undergoing general anesthesia. DESIGN: Randomized, prospective, double-blind study. SETTING: Large referral hospital. PATIENTS: 40 elderly patients ASA physical status I-III (> 65 years) undergoing abdominopelvic surgery with an estimated surgical time of at least 90 minutes. INTERVENTIONS: All patients received combined epidural-general anesthesia. After establishing a T6 sensory blockade, patients were randomized to receive either thiopental or propofol for induction of general anesthesia. The induction drug was slowly titrated until loss of eyelash reflex was noted. Thereafter, all patients received desflurane (2% to 3% end-tidal) and 70% nitrous oxide (N2O) in oxygen for maintenance of general anesthesia. To facilitate tracheal intubation, intravenous alfentanil 10 micrograms/kg and atracurium 0.4 mg/kg were administered. Perioperative analgesia was maintained with epidural bupivacaine. MEASUREMENTS AND MAIN RESULTS: A digit substitution test (DSST) and shape-sorter test, as well as patient-generated 100-mm visual analog score (VAS; 0 = minimal and 100 = maximal) for anxiety, sleepiness, and coordination, were performed during the preanesthetic interview, on postanesthesia care unit admission, and at 15, 45, 90, and 120 minutes thereafter. To induce loss of consciousness, either thiopental 2.5 +/- 1.0 mg/kg or propofol 1.6 +/- 0.6 mg/kg was administered. The mean anesthetic time was 109 +/- 30 minutes and 114 +/- 38 minutes for the thiopental and propofol groups, respectively. Emergence, extubation, and orientation times, as well as time to follow commands, were unaffected by patient randomization. Similarly, the DSST and shape-sorter tests, in addition to the patient-generated VAS for pain, anxiety, and coordination, were similar among groups. However, irrespective of treatment modality, return to baseline digit substitution and shape-sorter scores were significantly delayed (p < 0.01). CONCLUSION: When compared to thiopental, propofol does not facilitate improved cognitive recovery in geriatric patients undergoing prolonged surgery.
UNLABELLED: Nonsteroidal antiinflammatory drugs (NSAIDs) have become increasingly popular in the treatment of perioperative pain. Due to concerns that cyclooxygenase inhibition may adversely affect renal function, these drugs are often not used in geriatric surgical patients. However, the perioperative effect of NSAIDs on renal blood flow (RBF) and glomerular filtration rate (GFR) has not been assessed. Therefore, using a prospective, controlled, double-blinded study design, we evaluated the effect of diclofenac on RBF and GFR in 20 patients (>65 yr) undergoing open reduction and internal fixation of the femur. All patients were normovolemic before the study. A standardized general anesthetic was administered. On induction of anesthesia, patients in the diclofenac group received an IV bolus of diclofenac (0.7 mg/kg) followed by a constant infusion (0.15 mg x kg(-1) x h(-1)) until the end of surgery. In the saline group, an equal volume of saline was administered. During four time periods (equilibration, anesthesia, surgical, recovery), GFR and effective renal plasma flow (ERPF) were measured by inulin and paraaminohippurate clearance, respectively. After the induction of anesthesia and throughout the surgical period, ERPF and GFR were significantly decreased compared with preoperative baseline values. However, no difference was demonstrated between the groups. These results suggest that, in geriatric surgical patients, the adjuvant administration of NSAIDs does not adversely affect renal function. IMPLICATIONS: As determined by inulin and paraaminohippurate clearance, the intraoperative administration of diclofenac does not decrease glomerular filtration rate or effective renal plasma flow in normovolemic geriatric patients. Therefore, diclofenac may be administered during the perioperative period.
UNLABELLED: Both acute normovolemic hemodilution (NVHD) and tranexamic acid (TA) are potentially useful allogeneic blood conservation strategies after total knee replacement. However, the relative efficacy of these blood-sparing techniques is unknown. Therefore, to compare the postoperative allogeneic blood sparing of NVHD and TA after total knee replacement, we investigated 40 patients in a prospective, single-blinded study protocol. In Group TA, 30 min before deflating the limb tourniquet, an IV infusion of TA, 15 mg/kg, was administered over a 30-min period. Thereafter, a constant IV infusion of 10 mg x kg(-1) x hr(-1) was administered until 12 h after deflation of the limb tourniquet. Before induction of anesthesia, NVHD patients were bled to a target hematocrit of approximately 28%. Intravascular blood volume was maintained with lactated Ringer's solution. All autologous blood was transfused at the end of the surgery. Postoperatively, hematocrit was measured daily. In all cases, a hematocrit <27% was the postoperative transfusion trigger. Before discharge, deep vein thrombosis was excluded by Echo Doppler. Three months after surgery, the incidence of delayed thromboembolic events was assessed. The two groups were demographically comparable. In Group NVHD, 843 mL+/-289 of autologous blood was removed. Despite autologous blood transfusion, during the early postoperative period and until the third postoperative day, the NVHD group had significantly (P < 0.01) lower mean hematocrits when compared with the TA group. Thereafter, because of a significantly (P < 0.0008) greater allogeneic blood requirement in the NVHD group, no statistically significant difference in mean hematocrit recordings was noted among the groups. Blood accumulation in the surgical drain 12 h postoperatively, was significantly (P < 0.0008) higher in the NVHD group (259 mL+/-156) when compared with the TA group (110 mL+/-62). Significantly (P < 0.0008) more allogeneic blood was transfused in the NVHD group (19 U/13 patients) when compared with the TA group (2 U/2 patients). No abnormal Echo Doppler studies were reported. During the 3-mo follow-up period, a deep vein thrombosis and pulmonary embolus were documented in one patient in the NVHD group. We conclude that perioperative hemodynamic stability and allogeneic blood sparing is superior after tranexamic acid administration when compared with normovolemic hemodilution. IMPLICATIONS: For total knee replacement, when compared with normovolemic hemodilution, tranexamic acid administration is associated with superior perioperative hemodynamic stability and allogeneic blood sparing.
OBJECTIVE: To assess the value of adding remote pointer and dynamic display capabilities to a telemedicine system designed to provide consultative services for patients with congenital heart disease. MATERIAL AND METHODS: Independent observations by the referring physician and the consulting physician provided the data for the assessment. Fifty-four teleconsultations involving 38 patients with 21 different congenital heart diseases were analyzed. The teleconsultations were based on previously obtained cineangiograms that were digitized and then transmitted by combined satellite and terrestrial-based technology. The observations, recorded by each physician at his workstation at the time of each teleconsultation, were summarized and analyzed statistically. RESULTS: In 108 observations, the pointer was believed to be helpful in 72 (67%), and dynamic display was helpful in 96 (89%). CONCLUSION: This study suggests that use of a pointer and dynamic display enhances teleconsultations for patients with congenital heart disease.
UNLABELLED: To assess the effect of IV midazolam premedication on recovery of cognitive function, 90 geriatric patients (aged 65-81 yr) undergoing brief transurethral procedures were enrolled into this prospective, placebo-controlled, double-blinded study. In all cases, a standard general anesthetic was administered. Thirty minutes before operating room transfer, patients in Group 0.5 mg, Group 2 mg, and Group S received 0.5 mg of midazolam, 2 mg of midazolam, or an equal volume of saline, respectively. Before study-drug administration (baseline), at 15 min thereafter, as well as on arrival in the postanesthesia care unit (PACU), and at 60 min and 120 min, postoperatively, we administered a digit-symbol substitution test, a mini-mental test, a shape-sorter test, and a patient-generated 100-mm visual analog score (0 = minimal and 100 = maximal) for anxiety, sleepiness, and coordination. A 4-point scale was used to assess the degree of patient sedation at 7, 15, and 30 min after study-drug administration. Using a modified Aldrete scoring system, PACU discharge was determined by the PACU staff. Patient anxiety, sleepiness, and coordination scores at baseline and at 15 min after study-drug administration were similar. When compared with saline, midazolam was associated with a significantly (P < 0.05) higher incidence of "deep" sedation. In Group 2 mg, the incidence of a low preoperative Spo2 (<94%) was significantly (P < 0.05) higher when compared with Group S. Emergence, extubation, and orientation times, as well as time to follow commands were unaffected by midazolam premedication. Postoperatively, the digit-symbol substitution test, mini-mental test, and shape-sorter test were similar among the groups. However, time to PACU discharge was significantly (P = 0.03) longer in the two midazolam treatment groups (41 +/-25 min, 60 +/- 32 min, 53 +/- 39 min for Groups S, 0.5 mg, and 2 mg, respectively). Finally, patient satisfaction was unaffected by the randomization schedule. IMPLICATIONS: IV premedicant midazolam 0.5 mg or 2 mg does not adversely affect mental and psychomotor recovery in geriatric patients undergoing brief surgical procedures. However, midazolam administration significantly prolonged postanesthesia care unit discharge time. Finally, during the preoperative period, midazolam increases the incidence of a Spo2 <94% in a dose-dependent manner.
UNLABELLED: Epidural steroids are commonly administered in the treatment of "failed back surgery syndrome." Because patient response is dependent on accurate steroid placement, fluoroscopic guidance has been advocated. However, because of ever-increasing medical expenditures, the cost-benefit of routine fluoroscopy should be critically evaluated. Therefore, 50 patients were enrolled into this institutional review board-approved, prospective, controlled, single-blinded study. At a predetermined intervertebral level, the epidural space was identified using an air loss of resistance technique. Thereafter, an epidural catheter was inserted 2 cm through the epidural needle. To determine the accuracy of the clinical placement, contrast medium was administered through the epidural catheter; antero-posterior and lateral lumbar spine radiographs were then obtained. The number of attempts required to successfully locate the epidural space, the reliability of the air loss of resistance technique in indicating successful epidural penetration in failed back surgery syndrome, the ability of the clinician to accurately predict the intervertebral space at which the epidural injection was performed, and the spread of contrast medium within the epidural space were recorded. A total of 48 epidurograms were performed. The number of attempts to successfully enter the epidural space was 2 +/- 1. In 44 cases, the radiological studies confirmed the clinical impression that the epidural space had been successfully identified. In three patients, the epidural catheter was in the paravertebral tissue. One myelogram was recorded. In 25 patients, the epidural catheter did not pass through the predetermined intervertebral space. In 35 cases, the contrast medium did not reach the level of pathology. IMPLICATIONS: The clinical sign of loss of resistance is a reliable indicator of epidural space penetration in most cases of "failed back surgery syndrome." However, surface anatomy is unreliable and may result in inaccurate steroid placement. Finally, despite accurate placement, the depot-steroid solution will spread to reach the level of pathology in only 26% of cases.
PURPOSE: To present a case of respiratory depression following the administration of nebulised morphine. CLINICAL FEATURES: A 74-yr-old, 51-kg woman with a history of hypertension controlled with 5 mg.day-1 enalapril and 50 mg.day-1 atenolol was admitted for evaluation of low back pain, loss of appetite, and weight loss. Investigation revealed advanced metastatic disease with a probable primary in the right lung. The patient's pain was well controlled with 10 mg continuous release morphine p.o. three times daily, and 10 mg immediate release morphine p.o. for breakthrough pain as required. During the two weeks following the commencement of this treatment she occasionally complained of shortness of breath. Examination revealed a fully conscious patient with slight dyspnoea and mild wheezing which responded to oxygen 30% and nebulised bronchodilators. An oncological consultation recommended 4 mg nebulised morphine and 4 mg dexamethasone in saline as treatment for the bouts of breathlessness. Approximately 15 min after the first administration of nebulised morphine the patient became markedly bradypneic (respiratory rate: 4-5 bpm), hypotensive (BP 70/40 mmHg), and responded only partially to command. The pupils were pinpoint. The trachea was immediately intubated and the lungs ventilated with oxygen 40% for four hours. Following this occurrence of respiratory depression nebulised morphine was discontinued and no further events occurred. CONCLUSION: Patients receiving inhaled morphine should be closely monitored and resuscitation equipment should be readily available.
PURPOSE: We assessed the effect of intraoperative bupivacaine infiltration into the neurovascular bundle of the prostatic nerve on postoperative pain and patient outcome. MATERIALS AND METHODS: The study included 40 American Society of Anesthesiologists physical status I to III patients undergoing transvesical prostatectomy. Following surgical resection of the prostate the neurovascular bundle of the prostatic nerve was infiltrated with either 10 ml. bupivacaine 0.5% or saline. Postoperative pain intensity was assessed using a patient generated 100 mm. visual analog scale and a patient controlled analgesia device. Additional analgesic requirements, time to ambulation, length of hospitalization and return to normal activity were also recorded. RESULTS: There were no differences in visual analog scale for pain, patient controlled analgesia demands or actual morphine delivered. Similarly, saline versus bupivacaine infiltration did not influence ambulation time (21.3 +/- 2.7 versus 25.0 +/- 11.8 hours, respectively), length of hospitalization (7.06 +/- 0.8 versus 7.11 +/- 0.6 days, respectively), return to normal activity (14.4 +/- 8.8 versus 14.2 +/- 8.2 days, respectively) or patient satisfaction. On postoperative days 1 and 2 more patients in the saline treatment group requested additional oral analgesia compared to the bupivacaine treatment group. However, no statistical difference was demonstrated. CONCLUSIONS: Following transvesical prostatectomy, prostatic nerve blockade has no beneficial effects on postoperative pain or patient outcome.
STUDY OBJECTIVE: To compare the induction and recovery profiles of three combinations of general anesthesia when used as an alternative to spinal anesthesia for elderly patients. DESIGN: Randomized, prospective, open-label study. SETTING: Large referral hospital. PATIENTS: 100 [ASA physical status I, II, and III] patients over 60 years of age undergoing brief transurethral surgery. INTERVENTIONS: In Groups Propofol-Propofol (P-P), Propofol-Isoflurane (P-I), and Propofol-Desflurane (P-D), anesthesia was induced with fentanyl (1 to 2 micrograms/kg i.v.) and propofol (1.0 to 2.0 mg/kg i.v.) and maintained with 70% nitrous oxide in oxygen and either a propofol infusion (75 to 150 micrograms/kg/min) or isoflurane (end-tidal 0.7% to 1.2%) or desflurane (end-tidal 1% to 4%), respectively. After induction, a laryngeal mask airway was placed and spontaneous ventilation was maintained. In Group Spinal (S), 1.5 ml 4% lidocaine (60 mg), in an equal volume of 10% dextrose, was administered intrathecally. MEASUREMENTS AND MAIN RESULTS: Induction and recovery characteristics were compared. Induction with propofol was technically easier and significantly (medp < 0.0001) faster (4.6 +/- 1.7 min, 4.7 +/- 2.2 min, and 3.8 +/- 1.4 min for Groups P-P, P-I, and P-D, respectively) than induction of spinal anesthesia (9.3 +/- 3.4 min). During the induction period, mean arterial blood pressure and heart rate were significantly higher in Group S. Emergence, extubation, and orientation times were similar among the general anesthesia treatment groups. In Group S, patient-generated pain scores were lower (p < 0.05) and recovery room admission longer (p < 0.001). Time to return to baseline digit symbol substitution test (DSST) scores was marginally improved in Groups P-P and P-D when compared to Group P-I. Postoperative nausea, sleepiness, anxiety, and coordination were unaffected by the treatment modality. CONCLUSION: General anesthesia with propofol and desflurane facilitates shorter induction and recovery times without adversely affecting patient comfort. Therefore, this technique may be preferable to spinal anesthesia for elderly patients undergoing short transurethral surgical procedures.
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We hypothesized that the success of postoperative blood conservation after acute normovolaemic haemodilution (NVHD) is influenced by the extent of intraoperative bleeding and surgical trauma, and the timing of autologous blood transfusion. As total knee replacement is associated with minimal intraoperative but extensive postoperative blood loss, this procedure is ideally suited to acute NVHD. Therefore, to test our hypothesis, 30 patients undergoing elective total knee replacement were enrolled in a prospective, randomized, controlled study. In groups NVHD-2 and NVHD-6, before induction of anaesthesia patients were bled to a target packed cell volume (PCV) of 28-30%, and in the post-anaesthesia care unit autologous blood was transfused over a 2-h period terminating after operation at 2 and 6 h, respectively. In the control group, NVHD was not performed. After operation, platelets, fibrinogen, prothrombin and partial thromboplastin time, and liver function, urea and electrolytes were measured and compared with preoperative baseline values. Significantly (P < 0.024) more allogeneic blood was transfused in the control group (21 u.) compared with either group NVHD-2 (7 u.) or group NVHD-6 (5 u.). In the control group, despite the allogeneic blood transfusion, postoperative PCV decreased until day 4 after operation. Coagulation profile, liver function and urea and electrolytes concentrations were unaffected by the method of treatment. We conclude that for total knee replacement, acute NVHD is an effective blood conservation strategy. However, there was no difference in allogeneic blood administration between the two NVHD groups. Coagulation and liver function, and urea and electrolyte concentrations were unaffected by treatment.
To determine the antinociceptive effect of combining epidural fentanyl with lignocaine during non-immersion lithotripsy, 56 healthy patients were enrolled into a prospective, randomized, double-blind study. Epidural anaesthesia was induced with either lignocaine 300 mg alone, or lignocaine 300 mg, or 200 mg in combination with fentanyl 100 micrograms. Throughout the procedure analgesia was assessed by comparing the incidence of (a) spontaneous complaints of pain, (b) patients' attempts to withdraw from the painful stimulus, (c) supplemental epidural lignocaine requirements, (d) the haemodynamic response to lithotripsy and (e) the time to first postoperative pain. The patients who received the fentanyl-lignocaine 300 mg combination required no supplemental lignocaine, experienced marginally less intraoperative pain and recorded lower mean arterial blood pressures when compared with lignocaine 300 mg alone. However, when the combination of lignocaine 200 mg and fentanyl 100 micrograms was administered, patients experienced significantly more pain, withdrew from the painful stimulus more often and received more supplemental lignocaine when compared with the other two treatment groups. No difference was found in the time to the first complaint of postoperative pain. Similarly, discharge times were unaffected by treatment modality. We conclude that despite the addition of fentanyl, adequate analgesia during lithotripsy is dependent upon the dose of local anaesthetic administered.
Two cases of massive hemorrhage following blind introduction of laparoscopic instruments are presented. The role of the anesthesiologist in the early diagnosis of potentially life-threatening complications of laparoscopic surgery is discussed.