Large subcutaneous hematoma complicating epidural block

We present a case of a large subcutaneous hematoma in the lumbar region that occurred after epidural block was performed for the relief of labor pain. Epidural analgesia was begun in a young and healthy primigravida. Eight hours later, she needed an emergency cesarean section. Before anesthesia, blood was observed flowing freely around the site of the catheter insertion. General anesthesia was administered. Postoperative computed tomography showed a large subcutaneous hematoma in the lumbar region. Her postpartum course was complicated by an unexplained fever, which responded to antibiotic therapy and warranted prolonged hospitalization. Coagulation and bleeding studies were normal. We conclude subcutaneous hematoma after epidural block can cause significant morbidity and should be added to the list of neuroaxial block complications.

The postanaesthesia care unit as a temporary admission location due to intensive care and ward overflow

BACKGROUND

With the increasing number of critically ill patients, and shortage of intensive care unit and ward beds, some postoperative patients stay for an unnecessarily long period in the postanaesthesia care unit (PACU), until a suitable bed is available.

METHODS

We prospectively studied this patient overflow admission to the PACU over 33 months. Four hundred patients with a mean age of 53.1 yr (range 0.2-94) were studied. Two hundred and eighty one (70.3%) patients were mechanically ventilated on admission to the PACU and 311 (77.8%) had invasive monitoring. Mean length of stay in the PACU was 12.9 (SD 10.6) h.

RESULTS

The busiest hours of admission were 01-11 am. Eighteen (4.5%) patients died in the PACU, while waiting for an intensive care unit bed. The main problems were insufficient medical and nursing coverage, and inadequate communication and visiting facilities for patient's families.

CONCLUSION

Patient overflow to the PACU is a common problem that requires attention. Guidelines for medical and nursing coverage, patient triage, and communication with relatives need to be outlined.

International, multicentre, placebo-controlled study to evaluate the effectiveness of ondansetron vs. metoclopramide in the prevention of post-operative nausea and vomiting

Ondansetron 4 mg was compared with metoclopramide 10 mg for prevention of post-operative nausea and emesis in in-patients undergoing major gynaecological surgery in this double-blind, randomized, placebo-controlled, multicentre study. A total of 1044 patients received a single intravenous (i.v.) injection of study medication immediately before induction of anaesthesia. Nausea and emesis were assessed over the 24 h post-operative period. Significantly more patients who received ondansetron experienced no emetic episodes (44%) compared with those who received metoclopramide (37%, P = 0.049) or placebo (25%, P < 0.001). No nausea was experienced by significantly more patients who received ondansetron (32%) than with patients who received metoclopramide (24%, P = 0.009) or placebo (16%, P < 0.001). In addition, fewer emetic episodes, less severe nausea and a reduced need for rescue antiemetics were also observed with ondansetron (P < 0.05 vs. metoclopramide and placebo). Metoclopramide and placebo-treated patients were also 1.5 times (95% Cl 1.5-4.2) and 2.5 times (95% Cl 1.1-2.0) more likely, respectively, to experience nausea post-operatively. Overall, ondansetron was the most effective antiemetic in this patient population.

A comparison between arterial- and venous-sampled activated clotting time measurements

In order to compare activated clotting time (ACT) sampled from an arterial (heparin-flushed) line with the control, a venous (heparin-free) line, arterial and venous ACT values were assessed before and after cardiopulmonary bypass in 150 patients while undergoing open-heart surgery. ACT was measured by Hemochron 801 automatic analyzer. Baseline arterial ACT was significantly higher than baseline venous ACT (14%; p < 0.001, using one-way analysis of variance and Bonferroni multiple comparisons test). The differences between the values of arterial and venous ACT after protamine reversal, between arterial ACT at baseline and after protamine reversal, and between venous ACT at baseline and after protamine reversal were not statistically significant. We conclude that arterial-sampled ACT measurement is suitable and reliable for monitoring heparin reversal by protamine after cardiopulmonary bypass.

The utility of routine postoperative chest radiography in the postanesthesia care unit

STUDY OBJECTIVE

To evaluate the clinical significance and cost effectiveness of routine chest radiographs in the postanesthesia care unit (PACU).

DESIGN

Prospective study.

SETTING

University hospital.

PATIENTS

100 patients who were admitted to the PACU following various surgical procedures, and in whom a postoperative chest radiograph was routinely performed.

INTERVENTIONS

Chest radiograph was taken in each study patient soon after admission to the PACU. The indications for postoperative chest radiograph were: thoracotomy (30 patients), thoracoscopy (7), central vein catheterization (CVC) (75), pulmonary artery catheterization (3), and mechanical ventilation (36). A staff anesthesiologist examined each patient, evaluated each chest radiograph, and decided if a treatment action was to be taken. A chest radiologist later evaluated each chest radiograph, and her interpretation was compared with the anesthesiologist's interpretation to assess if this may affect patient management.

MEASUREMENTS AND MAIN RESULTS

The anesthesiologist found eight abnormal chest radiographs (8%): three with pulmonary congestion, four in whom the CVC was in the right atrium, and one with malpositioned CVC. In four patients (4%), the chest radiographic findings directly affected patient management. The radiologist confirmed the anesthesiologist's interpretation and found four additional abnormalities: one pulmonary congestion, one malpositioned CVC, and two chest radiographs, each with a small pneumothorax.

CONCLUSIONS

Abnormal chest radiographic findings resulted in a change in the management of only 4% of the patients. Therefore, the yield of a routine postoperative chest radiograph in the PACU is low. Performing a chest radiograph for a specific indication rather than on a routine basis, may decrease work load and save expenses. Postoperative chest radiography can be safely evaluated by a staff anesthesiologist.

Pain-evoked potentials: what do they really measure?

Cerebral evoked potentials (EPs) in response to painful stimuli have been recorded since the 1970s. Based on the apparent relationship of the response amplitude to intensity of stimulation, these potentials are conventionally interpreted as reflecting the sensory-discriminative aspects of pain. As such, pain-EPs provide an objective measure for sensation of pain. An alternative interpretation regards the pain-EP as comprised of at least two overlapping components, one pain-specific, the other, a P300 wave. In the case of pain, the P300 may reflect the degree of discomfort or unpleasantness, thus reflecting the emotional-motivational aspect. To establish the nature of the pain-EP, mini doses of a benzodiazepine, counterbalanced with placebo, were given to 6 normal volunteers. Benzodiazepines decrease anxiety, and so diminish the emotional response to pain, but they have no analgesic effect. In all subjects, pain perception was unchanged, while the EP wave was almost completely obliterated. We conclude that the pain-EP reflects the emotional-motivational response to pain rather than the sensory-discriminative. Thus, it provides a useful neurophysiological tool for studying the emotions associated with pain.

Near-sitting position and two-lung ventilation for endoscopic transthoracic sympathectomy

OBJECTIVE

To control for hypoxemia during endoscopic transthoracic sympathectomy, usually by using double-lumen tube and one-lung ventilation, a different anesthetic technique was adopted.

DESIGN

A prospective clinical study.

SETTING

A university-affiliated medical center.

PARTICIPANTS

Twenty-one adult patients (10 male and 11 female) between 15 and 44 years of age (mean, 22 years), ASA (American Society of Anesthesiologists) physical status I and II, participated in the study.

INTERVENTIONS

Under general anesthesia, a single-lumen endotracheal tube was inserted. The radial artery was cannulated for blood pressure monitoring and blood gas sampling. Patients were gradually raised from a supine position to 60 to 70 degrees from the horizontal plane. Mean fractional inspiratory O2 ratio was 0.4 +/- 0.02 (mixture of O2 and air) throughout the operation. Blood gas samples were taken during two-lung ventilation before surgery, at each one-chest operation, and when switching between the operated chest sides. An artificial pneumothorax was established by insufflation of CO2, the sympathetic chain coagulated, the pneumothorax released, and the lung reinflated.

MEASUREMENTS AND MAIN RESULTS

Comparisons were performed using one-way analysis of variance and the Bonferroni post-test. Arterial O2 partial pressure at right- and left-chest operation were 209 +/- 83 and 189 +/- 63 mmHg, respectively, compared with 227 +/- 43 and 241 +/- 69 mmHg on two-lung ventilation before and during surgery, respectively. O2 saturation, arterial CO2 partial pressure, bicarbonate, base excess, peak inspiratory pressure, and hemodynamic parameters (in most patients) did not change throughout the operation.

CONCLUSIONS

The near-sitting position, a single-lumen tube, and a continuous two-lung ventilation technique is simple and may prevent hypoxemia during endoscopic transthoracic sympathectomy.

Left, but not right, one-lung ventilation causes hypoxemia during endoscopic transthoracic sympathectomy

OBJECTIVE

To describe the respiratory and cardiovascular effects of one-lung ventilation, using a double-lumen tube, during endoscopic transthoracic sympathectomy.

DESIGN

A prospective clinical study.

SETTING

A university-affiliated medical center.

PARTICIPANTS

Nineteen adult patients (10 men, 1 woman) between 16 and 35 years of age, ASA (American Society of Anesthesiologists) physical status I and II, participated in the study.

INTERVENTIONS

Endoscopic transthoracic sympathectomy was performed under general anesthesia, using a double-lumen endobronchial tube, after induction of artificial pneumothorax plus insufflation of CO2 into the operated chest. Via radial artery cannulae, one to three arterial blood gas samples were taken during two-lung ventilation before surgery, at each one-lung ventilation, in most cases during the period of two-lung ventilation when switching between the operated sides, and after surgery.

MEASUREMENTS AND MAIN RESULTS

Comparisons were performed using the Wilcoxon matched-pairs single-ranks test. Left-lung ventilation and right-chest operation caused profound decrease of arterial oxygen partial pressure (PaO2), compared with two-lung ventilation before surgery (70.7%, P > 0.0003) and compared with PaO2 at two-lung ventilation during and after surgery (decrease of 80.1% and 75.3%, respectively; P > 0.001 and < 0.005, respectively). Right-lung ventilation and left-chest operation did not cause hypoxemia. Arterial CO2 partial pressure, pH, and bicarbonate, as well as hemodynamic parameters, did not change from baseline values throughout surgery.

CONCLUSIONS

Pulse oximetry and repeated blood gas measurements are needed during endoscopic transthoracic sympathectomy in order to detect and treat hypoxemic events, which may jeopardize the patient's life.

Induction of anesthesia with propofol in urological outpatient surgery

Propofol (Diprivan) in a new formulation, a short-acting intravenous anesthetic, was used as an induction agent for short urological procedures. Forty unpremedicated patients were treated with either propofol or thiopental in a randomized study. The onset of anesthesia and duration of apneic period were prolonged and the decrease in systolic blood pressure was more profound in the propofol group. Heart rate was less stable and recovery time was longer in the thiopental group. Other parameters, such as quality of anesthesia, acceptability of the drug or rate of side effects, were similar in both groups. These results suggest that propofol in a new formulation is a suitable agent for short urological procedures in outpatient surgery.

Hypokalemic familial periodic paralysis: a case report

The perioperative management of patients with hypokalemic familial periodic paralysis is well known and has been described previously. This disease does not preclude surgery as long as the surgical team is aware of the diagnosis preoperatively. We describe herein a patient with familial periodic paralysis diagnosed the first time 1 day after undergoing surgery.

Fiberoptic bronchoscopy with general anesthesia using a transvector for ventilation

A transvector, a highly efficient flow amplifier, until present in use only in industry, has been adapted to the ventilation of patients during fiberoptic bronchoscopy under intravenous general anesthesia. The transvector is connected directly to an endotracheal or tracheostomy tube and provides an open unobstructed passage of the instrument into the patient's airways. The method combines safety with ease of instrumentation and uniformly satisfactory ventilation has been obtained in 25 patients.