[General anesthesia or conduction anesthesia in cesarean section].
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Analgesia↗
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[Anesthesia in otorhinolaryngology with special reference to endotracheal intubation anesthesia].
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Anesthesia↗
Pulmonary arterial catheterization before anesthesia in patients undergoing cardiac surgery. Placement of the pulmonary arterial catheter before anesthesia for cardiac surgery: safe, intelligent, and appropriate use of invasive hemodynamic monitoring.
Should one catheterize the pulmonary artery (PA) for cardiac surgery before or after induction of anesthesia? Issues of central importance to this question include (1) the patient's preexisting hemodynamic abnormalities, (2) cardiovascular effects of anesthetic induction drugs, and (3) hemodynamic stress caused by laryngoscopy, endotracheal intubation, and PA catheter insertion. Some clinicians use the PA catheter immediately before anesthetic induction to detect and correct acute abnormalities in preload and ventricular function. This approach has been described as being partially responsible for decreased morbidity and mortality in patients with cardiovascular disease. Hemodynamic instability during induction has been reported with many of the common anesthetic induction agents, especially in patients with poor ventricular function. Since blood pressure is the product of cardiac output and systemic vascular resistance, accurate interpretation and treatment of hypotension are possible only when these variables are provided by vigorous use of the PA catheter. Early detection of myocardial ischemia is possible with examination of acute changes in the pulmonary capillary wedge pressure tracing. However, the lack of such information can restrict even the best anesthetist. Insertion of the PA catheter in the awake patient can be accomplished effectively and with minimal risk, so long as good patient rapport, adequate premedication, and continuation of antianginal medication until the time of surgery are assured. Preinduction placement of the PA catheter provides valuable, objective information for the cardiac anesthesiologist without incurring significant risk to the patient.
Anesthesia↗
Continuous retrobulbar anesthesia for scleral buckling surgery using an ultra-fine spinal anesthesia catheter.
PURPOSE: To evaluate a novel retrobulbar catheter technique for intraoperative and postoperative analgesia in patients undergoing scleral buckling procedures. METHODS: This prospective noncomparative clinical interventional case-series study included 43 consecutive patients undergoing scleral buckling procedures as treatment of rhegmatogenous retinal detachments. Using a commercially available retrobulbar needle with a diameter of 0.80 mm and a length of 38 mm, 7 mL of local anesthetic were injected into the retrobulbar space. Through the same needle, a 28-gauge commercially available flexible spinal anesthesia catheter was introduced into the retrobulbar space, the needle was withdrawn, and the catheter was fixed. The catheter was removed on the morning of the first postoperative day. When the patients started to feel pain during or after surgery, 2 mL of local anesthetic were re-injected through the catheter. RESULTS: During surgery, 12 (27.9%) patients received a pain-free re-injection through the retrobulbar catheter resulting in a marked reduction of pain. Two (4.7%) patients needed a second re-injection. In the postoperative period, 23 (53.5%) patients experienced pain of grade 3 or higher 5.4 +/- 6.7 hr after start of surgery and received a retrobulbar re-injection. Eleven (25.6%) patients asked for a second postoperative re-injection, and four (9.3%) patients received a third postoperative re-injection. Cardiopulmonary and central nervous adverse effects were not noticed. CONCLUSIONS: Use of an ultra-fine retrobulbar catheter for repeat intraoperative and postoperative injections of local anesthetics is a simple and effective method to achieve analgesia during and after scleral buckling procedures.
Aged↗
[The anesthesia of anesthesia].
Viewed from a cultural-ethical perspective, anesthesiology can be understood as a comprehensive concept of medicine in general. As such it contains two dilemmas: very often pain must be inflicted in order to alleviate pain and this can only be done by somebody who is himself relatively free of pain. The necessary apathy or anesthesia of the anesthetist is correlated with a general twentieth century-type of perception: the cool observer. Nevertheless, it is also a modern variation of the original religious constellation of the priest in relationship to the sick person. Curing occurs by representation. The weak self of the sick person is able to take over the strong self, represented by the therapist. In twentieth century art and literature this process of self-therapy by representation was often illustrated. On the background of a phenomenological philosophy that process can be understood as the regaining of a balance between body and soul. In the psalms of the biblical Book of Job there a variety of fundamental forms of pain which may be helpful even in this secular age.
Anesthesia↗
A rabbit model for evaluation of surgical anesthesia and analgesia: characterization and validation with isoflurane anesthesia and fentanyl analgesia.
PURPOSE: With a clamp test, quantitative estimation of the level of surgical anesthesia/analgesia is not easy. We have developed a rabbit pain model allowing for quantitative evaluation of the level of surgical anesthesia/analgesia using both electrical and mechanical stimuli as simulated surgical stimuli. We evaluated whether this model allows for accurate tracing of dynamically changing levels of surgical anesthesia/analgesia induced by isoflurane and fentanyl. METHODS: Eight rabbits tracheotomized and vascularly cannulated under 3% isoflurane anesthesia were placed on a sling that allowed for free movement of the head and extremities. After the isoflurane concentration was reduced stepwise to 1.5% and then to 0%, four graded doses of fentanyl (5, 10, 20, and 40 microg.kg(-1)) were injected intravenously at intervals of 120 min. At each dose, anesthetic/analgesic end-point variables were determined, including the number of animals behaviorally unresponsive to clamping the forepaw (nonresponders) and the threshold voltage of subcutaneous electrical stimulation (2, 5, and 50 Hz) required to evoke the head lift (HLT: pain detection/arousal threshold: sedative/hypnotic index) and the escape movement (EMT: pain tolerance threshold: analgesic index). RESULTS: With increasing doses of isoflurane and fentayl, HLTs and EMTs, especially those at 5 Hz, increased dose-dependently and proportionately to increases in the number of nonresponders to clamping the forepaw, a standard indicator of the anesthetic/analgesic level. CONCLUSION: Using the HLT and EMT, especially at 5 Hz, combined with a clamp test, this rabbit model allows for repeated, quantitative, and distinctive evaluation of the dynamically changing levels of both sedative/hypnotic and analgesic components of surgical anesthesia/analgesia.
Analgesia↗
Comparison of one-injection-site peribulbar anesthesia and retrobulbar anesthesia.
One hundred patients having elective cataract surgery were evaluated in a prospective, randomized, double-blinded study comparing retrobulbar and peribulbar anesthesia. Patients were divided into two study groups and evaluated on three criteria felt to be critical to intraocular surgery. Results showed that the efficacy of the one-injection-site peribulbar block was similar to that of the retrobulbar block for all three criteria. Because the one-injection-site anesthetic is administered outside the muscle cone, the potential for optic nerve and central nervous system complications should be minimized.
Anesthesia, Local↗
[Single-shot spinal anesthesia versus continuous spinal anesthesia using the CoSPAN catheter].
OBJECTIVE: We compared conventional single-shot spinal anaesthesia (SS) with continuous spinal anaesthesia (CS) in a randomised prospective study. PATIENTS AND METHODS: Sixty patients undergoing urological surgery received either SS (n = 30) using an atraumatic needle or CS (n = 30) using a CoSPAN catheter. Prior to performing the spinal anesthesia, patients were prehydrated with 250 ml of hydroxyethyl starch 10%. Spinal anaesthesia was performed with the patients in the sitting position at L3-4 interspace. In the CS group CSF was aspirated via the catheter to check its correct position, and initially 0.5 ml of hyperbaric 5% lidocaine were injected. 0.25 ml boli at 5 min intervals were repeated as often as necessary to reach the desired sensory blockade up to the T10 segment. In patients undergoing the single-shot technique 1.5 to 3.5 ml of hyperbaric 0.5% bupivacaine was injected. After performing the block, haemodynamic parameters were assessed for 20 minutes at 2 min intervals, before and thereafter at 5 min intervals. The required time for recovery of motor activity of the legs was assessed postoperatively. The patients were visited on the 1st, 3rd and 5th postoperative day and asked about possible headache. RESULTS: The CoSPAN spinal catheter was easy to handle. CSF could be aspirated via this catheter within 33.1 +/- 7.6 seconds. The desired maximum cephalad spread (T10) was exceeded by a mean of 0.63 +/- 1.3 segments in the CS group and by a mean of 1.4 +/- 2.6 segments in the SS group. In the SS group a mean volume of hyperbaric 0.5% bupivacaine of 2.59 +/- 0.4 ml was used. In the CS group a mean volume of 1.08 +/- 0.4 ml of hyperbaric 5% lidocaine was necessary. In the SS group, mean arterial blood pressure was found to have significantly decreased to lower than the initial value within the first 20 min after injection at each of the 10 determinations. Maximal decrease of mean arterial pressure to 89.3 +/- 7.7% was registered 14 min after injection. In the CS group, only the measurement 14 min after injection of the initial bolus revealed a significant decrease of the mean arterial blood pressure to 94.2% of the initial value. The mean interval elapsed before motor function of the legs returned after the end of surgery was 67.7 +/- 50 min in the SS group and 26.7 +/- 15.4 min in the CS group. None of the 60 patients complained about postspinal headache. DISCUSSION: Fractionated injection of the local anesthetic via a spinal catheter was more precise in achieving the desired maximum cephalad spread than SS. The CS group revealed a significantly more stable blood pressure than the SS group. The use of a short-acting local anesthetic for CS provided an earlier postoperative return of motor function of the legs. Postspinal headache appears not to be a clinically relevant problem when 28-gauge spinal catheters are used.
Aged↗
[Epidural anesthesia in surgical interventions on the spine and spinal cord. II. Effects of epidural anesthesia on somatosensory evoked potentials].
Effects of epidural anesthesia (EA) on early components of somatosensory evoked potentials (SSEP) were studied and the objectiveness and efficiency of SSEP monitoring during interventions on the spine under EA were evaluated. Evoked potentials were studied in 21 patients operated on for vertebral disk hernias and extra-intradural tumors of the spine (lower thoracic and lumbar levels) under bupivacaine EA. Cortical SSEP were recorded and analyzed on a Viking IV neuroaverager (Nicolet, USA) stimulating n. tibialis posterior for obtaining a greater amplitude of evoked potentials. The following SSEP characteristics were measured: latency of PI (P37), NI (N45), and PII (P60) peaks, amplitude of PINI peak, and inter-peak latency of PI-NI and PI-PII. The major changes in cortical SSEP caused by EA (local anesthetic 0.5% bupivacaine) involve only PI and NI components which reflect the entry of information on an external stimulus into the cortex and objective physical parameters of this stimulus; this helps predict the onset of full-value epidural block and its duration. General anesthetic (propofol) affect mainly a later component of response, PII peak, which is responsible for processing of primary information about an external stimulus and reflects the activation of associative areas of the brain. Hence, SSEP regulation can be used together with traditional methods (pin prick test and Bromage scale) for evaluating epidural block in patients with spinal diseases.
Adult↗
[Comparison between Greenbaum's parabulbar anesthesia and Ripart's subtenon anesthesia in the anterior segment surgery].
PURPOSE: To compare two methods of sub-tenon anesthesia in 80 surgical procedures (phakoemulsification, glaucoma and combined surgery) in a prospective, single-surgeon study. MATERIALS AND METHODS: Forty patients requiring anterior segment surgery in each eye were randomised to receive subtenon anaesthesia by either Greenbaum's method (using a flexible plastic cannula) or Ripart's method (using a 23G hypodermic needle). Randomization dictated the mode of anaesthesia for the first eye, the other technique being used for the second eye. Anaesthesia consisted of 1.5ml lidocaïne 2% and 1.5ml bupivacaïne 0.5% in all cases, and was performed by the same surgeon (EDLM) immediately before surgery. Type of surgical procedure, duration, complications, presence of sub-conjunctival haemorrhage, were assessed by the surgeon, who also graded chemosis (0-3), nuclear hardness (1-4), and ocular akinesia (0-2) for each patient. Pain was scored subjectively by each patient (0-10) during the injection, peroperatively and postoperatively. RESULTS: Chemosis was significatively higher with Greenbaum's method than Ripart's method (p<0.01) and was sometimes undesirable for the surgeon. There was no difference in the pain score during the injection, preoperatively or postoperatively. Pain was usually very light and did not correlate with the duration of surgery. There was no akinesia in the majority of cases with either method, but the surgeon was sometimes limited by the akinesia of the medial rectus muscle and often by that of the inferior rectus muscle with elevation of the globe. CONCLUSION: Greenbaum's method and Ripart's method are two subtenon anesthesic techniques characterized by an immediate, intense and prolonged analgesia (sometimes 60mn). Complete akinesia is rare and this is sometimes limiting. Chemosis was more often associated with Greenbaum's method, but Ripart's method carries the potential for needle-related complications.
Anesthesia, Local↗
Principles of office anesthesia: part I. Infiltrative anesthesia.
The use of effective analgesia is vital for any office procedure in which pain may be inflicted. The ideal anesthetic achieves 100 percent analgesia in a short period of time, works on intact or nonintact skin without systemic side effects, and invokes neither pain nor toxicity. Because no single agent meets all of these criteria, the physician must choose from the available armamentarium based on the anesthetic properties that are most desired. Infiltrative anesthetics are frequently chosen because of their proven safety record, low cost, ease of storage, widespread availability, and rapid onset of action. Allergy to local injectable anesthetics is rare, and when it occurs it is often secondary to the preservative in multidose vials. Anesthesia can be prolonged with the addition of epinephrine or the use of longer-acting agents. Buffering the local anesthetic with bicarbonate, warming the solution, and injecting slowly can minimize the pain of anesthetic injection. Complications are rare but include central nervous system and cardiovascular toxicity, or extreme vasoconstriction in an end organ, if epinephrine is used.
Ambulatory Surgical Procedures↗
Principles of office anesthesia: part II. Topical anesthesia.
The development of topical anesthetics has provided the family physician with multiple options in anesthetizing open and intact skin. The combination of tetracaine, adrenaline (epinephrine), and cocaine, better known as TAC, was the first topical agent available for analgesia of lacerations to the face and scalp. Cocaine has been replaced with lidocaine in a newer formulation called LET (lidocaine, epinephrine, and tetracaine). For analgesia to nonintact skin, LET gel is generally preferred over TAC because of its superior safety record and cost-effectiveness. EMLA (eutectic mixture of local anesthetics) is perhaps the most well-known topical anesthetic for use on intact skin. EMLA can be used to anesthetize the skin before intramuscular injections, venipuncture, and simple skin procedures such as curettage or biopsy. To be fully effective, EMLA should be applied at least 90 minutes before the procedure. ELA-Max is a new, rapidly acting topical agent for intact skin that works by way of a liposomal delivery system and is available over the counter. Other delivery vehicles for topical anesthesia currently in development, including iontophoresis and anesthetic patches, may one day give patients and physicians even more flexibility.
Administration, Topical↗
Reversal of the central effects of midazolam by intravenous flumazenil after general anesthesia and use of a long-acting opioid in hospitalized patients: report of a multicenter double-blind clinical study. The Flumazenil in General Anesthesia in Hospitalized Patients Study Group II.
A double-blind clinical trial was conducted to evaluate the efficacy and safety of flumazenil, a benzodiazepine antagonist, in 146 hospitalized patients, who had had general anesthesia induced by midazolam and a long-acting opioid. Ninety-eight patients received flumazenil and 48 received placebo. Administered postoperatively at a mean intravenous dose of 0.84 mg (range: 0.2 mg to 1 mg), flumazenil reversed benzodiazepine-induced sedation to a greater extent than did placebo. At 5 minutes posttreatment, 61 (76%) of 80 flumazenil-treated patients and 7 (18%) of 40 placebo-treated patients had attained a score of 4 or 5 on the Observer's Assessment of Alertness/Sedation Scale, indicating that they were drowsy or fully awake and alert. This level of arousal was maintained for the full 180-minute posttreatment assessment period in 79% of flumazenil-treated patients. Between-group differences in mean change from baseline in level of alertness were statistically significant (P < 0.01) until 60 minutes posttreatment, when the spontaneous recovery of placebo-treated patients resulted in declining intergroup differences. The global efficacy rating (based on the physician's general impression of the effectiveness of the reversal of sedation 5 minutes after test drug administration) was good or excellent in 64 (80%) of the 80 flumazenil-treated patients and 5 (13%) of the 40 placebo-treated patients evaluated. Flumazenil, compared with placebo, was not associated with an increased frequency of operative-site pain, and no serious adverse effects of this benzodiazepine antagonist were reported. The most frequent adverse experiences in both treatment groups were nausea, shivering, and operative-site pain. Vomiting, dizziness, and injection-site reactions were also reported in > or = 5% of patients treated with flumazenil.
Adult↗
Reversal of the central effects of midazolam by intravenous flumazenil after general anesthesia in outpatients premedicated with an opioid and a muscle relaxant: report of a multicenter double-blind clinical study. The Flumazenil in General Anesthesia in Outpatients Study Group II.
Flumazenil was studied in a double-blind multicenter trial to confirm its efficacy and safety in antagonizing the central effects of benzodiazepines after general anesthesia (midazolam, short-acting narcotic, nitrous oxide) with muscle relaxants and selected potent volatile anesthetics as needed. One hundred seventy-two outpatients were randomly assigned to receive either flumazenil or placebo titrated to the point of reversal of sedation or a maximum dose of 1 mg of flumazenil or 10 ml of placebo. The test drug was given intravenously (0.2 mg flumazenil or 2 ml placebo) at 1-minute intervals. Tests of alertness, psychomotor function, and memory were conducted prestudy and at baseline before the administration of flumazenil and at 5-, 15-, 30-, 60-, 120-, and 180-minute intervals after administration. The changes from prestudy or baseline scores were analyzed to compare differences between treatment groups. Seventy-five percent of the 105 flumazenil-treated patients and 14% of the 55 placebo-treated patients who met the qualifications for efficacy evaluations obtained a criterion level of response as measured by the Observer's Assessment of Alertness/Sedation Scale. Most (76%) patients who were alert at 5 minutes maintained their level of wakefulness throughout the 180-minute observation period. All 172 patients were included in evaluations of safety. Fifty percent of 113 flumazenil-treated patients and 31% of 59 placebo-treated patients reported one or more adverse experiences. The most frequently reported were nausea, vomiting, and dizziness. Only 6 adverse effects in the flumazenil group and 1 in the placebo group were considered severe; the remainder were mild or moderate. None were considered serious or potentially serious. Postoperative administration of flumazenil (mean dose, 0.85 mg) safely provided a prompt, controlled reversal of the sedative and psychomotor effects of midazolam in most patients.
Adult↗
Reversal of the central effects of midazolam by intravenous flumazenil after general anesthesia in outpatients: a multicenter double-blind clinical study. The Flumazenil in General Anesthesia in Outpatients Study Group I.
In a US double-blind, multicenter study, flumazenil, a benzodiazepine antagonist, administered postoperatively in a mean intravenous dose of 0.67 mg (range, 0.2 to 1 mg), was superior to placebo in reversing sedation and other central nervous system effects of benzodiazepines in outpatients recovering from general anesthesia induced by midazolam, fentanyl or sufentanil, and nitrous oxide. Within 5 minutes after administration of flumazenil, sedation was reversed in 94% (87 of 93) of flumazenil-treated patients, compared with 13% (6 of 46) of placebo-treated patients. The criterion response (Observer's Assessment of Alertness/Sedation Scale score of 4 or 5) that was achieved at 5 minutes was maintained in 79 (93%) of 85 patients throughout the 180-minute observation period. Psychomotor performance, measured by the Finger-to-Nose Test, was rated as normal at 5 minutes posttreatment for 77% (71 of 92) of flumazenil-treated patients, and 4% (2 of 46) of placebo-treated patients. The reversal of amnesia, as determined by the Picture Recall Test was less consistent. Patients given flumazenil did not experience more pain at the operative site or require more analgesic medication than did those given placebo. Nausea (flumazenil 24%; placebo 15%), dizziness (flumazenil 12%; placebo 2%), and vomiting (flumazenil 10%; placebo 9%) were the most frequent adverse effects in each group. In conclusion, flumazenil provided prompt arousal from benzodiazepine-induced sedation and was well tolerated.
Adolescent↗
[Electrical dental anesthesia (EDA), an alternative to local anesthesia?].
Electrical dental anesthesia has recently been suggested as an alternative to local anesthetics for the control of pain related to certain dental acts. This article updates the evidence which supports the efficiency, indications and contra-indications of such a procedure. Although this technique has certain advantages, its use is limited by: 1) how cooperative the patient may be; 2) the time required to explain the procedure to the patient and that which is required to produce the needed clinical effect; and, 3) how efficient it may be relative to the patient in question and the dental treatment rendered.
Anesthesia, Dental↗
[Spinal anesthesia in ambulatory anesthesia of the infant].
Two hundred spinal anesthesias have been performed in infants for abdominal surgery, thirty of which for day surgery. Intrathecal injection of 0.5% bupivacaine solution is realised in good conditions, sometimes with narcosis complementation (ketamine or halothane). Motor block takes place without delay and lasts for an average of 95 +/- 25 minutes. There is no hemodynamic disturbance. This technic could be used in day surgery by reason of quick recovery.
Ambulatory Surgical Procedures↗
[Intraligamentary anesthesia as an adjunct to infiltrative and regional anesthesia].
This paper presents a brief summary of the different technics and materials in the periodontal ligament injection. The periodontal adverse effects are analysed. This technique is complementary of the conventional local anesthesia and should be used only by skilled clinicians.
Anesthesia, Dental↗