Oesophageal atresia: caudo-thoracic epidural anaesthesia reduces the need for post-operative ventilatory support

The mortality of neonates with oesophageal atresia in the Third World remains high because of delays in presentation and diagnosis. Lack of appropriate intensive care facilities is a further contributing factor. Caudothoracic epidural anaesthesia was used during surgical repair of oesophageal atresia in 35 patients in an attempt to minimise the need for post-operative ventionally support. This group was compared with 36 patients whose surgery was performed under general anaesthesia. The age at the time of referral, sex ratio, and weight were comparable in both groups. Using the Waterson classification, a greater number of poorer prognostic patients were seen in the epidural group (P <0.02). In all Waterson risk categories fewer patients required ventionally support post-operatively, which was statistically significant (P <0.01) when all categories were combined. We are encouraged by our results and believe this technique has a rôle in the management of neonates undergoing major surgery, both where neonatal intensive care exist or is deficient as in many parts of the Third World.     

Epidural Spinal Cord Infiltration: A Rare Complication of Acute Myeloblastic Leukaemia

Epidural infiltration by leukemic cells in Acute Non Lymphoblastic Leukemia (ANLL), and extradural granulocytic sarcomas as a cause of spinal cord compression are extremely rare phenomena. Very few cases have been recorded in the literature. In this brief case report we describe a young patient with acute myeloblastic leukemia (M4, FAB) who presented with sudden spinal cord compression during relapse after bone marrow transplantation. The literature on this subject is also reviewed.     

Subkapsularës leberhämatom bei HELLP-syndrom

Zusammenfassung Das HELLP-Syndrom (Hemolysis, Elevated Liver enzymes, Low Platelets) tritt als Komplikation einer Schwangerschaftspräeklampsie auf und kann zu ausgedehnten subkapsulären Leberhämatomen führen. Wegen der Rupturgefahr der Hämatome besteht eine lebensbedrohende Notfallsituation für Mutter und Ungeborenes. Anhand von 2 Fallbeispielen wird das interdisziplinäre Vorgehen diskutiert. Mit Diagnosestellung der subkapsulären Leberhämatome sollte die notfallmäßige Entbindung durch Sectio erfolgen. Dann kann die chirurgische Entscheidung für eine konservative, abwartende Therapie mit Intensivüberwachung oder für eine Notfalloperation im Falle einer Leberkapselruptur ohne vermeidbares Risiko getroffen werden.

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Subcapsular liver hematoma with HELLP-syndrome — an interdisciplinary urgency

Summary The HELLP-syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets), known as a complication during pregnancy, is associated with preeclampsia and may cause subcapsular liver hematomas. In case of hepatic rupture the lives of mother and unborn are threatened. Therefore, an interdisciplinary diagnostic and therapeutic approach is discussed and compared to two examples. The diagnosis of subcapsular liver hematoma must lead to urgent delivery through Cesarean section. Thereafter, the surgeon may decide between observation on an intensive care unit and urgent operation in case of hepatic rupture, without endangering the unborn.

     

Comparison of circulatory and respiratory responses between supplementary epidural buprenorphine and eptazocine administration during and immediately after total intravenous anesthesia

Opioid supplements are often required in total intravenous anesthesia (TIVA). Most ϰ-opiate receptors are found in the spinal cord, wherea μ-opiate receptors are widespread throughout the brain and spinal cord. Buprenorphine has a strong μ-action with a minute ϰ-action, while eptazocine stimulates ϰ-receptors only. From these, epidural eptazocine is expected to exert strong spinal analgesia by ϰ-stimulation without μ-action, which produces circulatory and respiratory depression. Therefore, the clinical effects of epidural opioids on circulation, respiration, and analgesia were compared. Continuous epidural administration of eptazocine or buprenorphine was combined with TIVA in patients scheduled for elective abdominal surgery. Epidural opioid administration was continued throughout and for 72h after anesthesia. A significant analgesic effect (P<0.01) of epidural eptazocine without circulatory and respiratory depression was observed. With epidural buprenorphine, circulatory and respiratory depression during and immediately after anesthesia were significant (P<0.05). These results suggest that medullary μ-stimulation by an epidural opioid induces circulatory (hypervagotonicity and hypervagosensitivity) and respiratory depression, while ϰ-stimulation produces only minimal effects on circulatory and respiratory systems.     

小剂量氯胺酮咪唑安定辅助硬膜外下剖腹产手术的临床探讨

目的对比观察剖腹产选用连续硬膜外麻醉时，辅助麻醉用药镇静及对牵拉反应抑制效果。方法选择行剖腹产手术产妇60例在硬膜外麻醉效果满意后，随机分两组各30例。Ⅰ组：哌替啶50mg，异丙嗪25mg单次静注。Ⅱ组：氯胺酮28．5mg，咪达唑仑1．42mg单次静注。分组记录用药前，1min，5min，15min及术毕产妇SpO2、RR、HR、MAP值；记录手术时间、术毕苏醒例数、术中恶心躁动例数；记录术毕产妇OAA／S评分；记录新生儿娩出时Apger评分。结果两组术中镇静、抑制牵拉反应效果均满意。两组RR、BP、HR、SpO2均平稳；术毕两组OAA／S评分均为4-5分；新生儿Apger评分均正常。结论两组方法效果确切，对产妇和新生儿安全。     

Clinical evaluation of a new epidural pressure monitor

Summary Comparative measuring of epidural pressure using the Spiegelberg probe 1 and ventricular fluid pressure was carried out in 15 neurosurgical intensive-care patients. Deviations in both directions were established, with a trend toward overestimating ventricular pressure in epidural pressure measuring (r=0.77). Individual pulsations, spontaneous wave courses and therapy-induced pressure changes were reflected without delays. There were no complications observed with probe implantation periods for up to 6 days. The system has been shown to be mechanically stable and easy to implant. We believe the device to be fit for trend monitoring of intracranial pressure. As with other epidural pressure monitoring systems, false assessments of ventricular pressure may lead to wrong decisions as to the required therapy.     

Intra-abdominal desmoplastic small cell tumor presenting as an acute abdomen after trauma

The intraperitoneal mass most commonly encountered after blunt abdominal truama is a hematoma. However, one must also consider unusual bulky tumors that can have imaging characteristics similar to those of hematoma. The most typical of these neoplasms is lymphoma, but a desmoplastic small cell tumor also may be observed. The presentation and imaging findings of a desmoplastic small tumor are described.     

Favorable effects of epidural analgesia on hemodynamics,oxygenation and metabolic variables in the immediate post-anesthetic period

Fourteen adult patients undergoing elective major abdominal surgery were divided into two groups. One group received epidural and general anesthesia (epidural group), and 20 ml of 0.125% bupivacaine and 2 mg of morphine were administered epidurally about 30 min before the end of the operation for post-anesthetic analgesia. The other group (control group) received general anesthesia alone with nitrous oxide, oxygen and enfiurane. Flow-directed pulmonary arterial and radial arterial catheters were inserted preoperatively, and hemodynamic, respiratory, neuroendocrine and metabolic variables were measured serially. The data were compared during anesthesia and the immediate post-anesthetic recovery period. In the control group, the plasma epinephrine level in the post-anesthetic recovery period increased about four times over the anesthetic period. Oxygen consumption was increased and mixed venous oxygen saturation was decreased significantly. There was a close linear correlation between oxygen consumption (Y) and plasma epinephrine (X) level: Y = 285.7X + 90.5 (P < 0.01, r = 0.72). On the other hand, plasma epinephrine, oxygen consumption and mixed venous oxygen saturation did not change significantly in the epidural group in the post-anesthetic recovery period. There was also a close linear correlation between oxygen consumption (Y) and oxygen delivery (X): Y = 0.22X -32.0 (P < 0.01, r = 0.89). We conclude that the surgical stress and anesthetic reversal may seriously influence neuroendocrine responses and subsequently increase plasma epinephrine. Tissue oxygenation and metabolic imbalance may occur due to the rapid increase of epinephrine in the postanesthetic recovery period. Epidural analgesia at this period may play a more important role and have a more favorable effect on the tissue metabolism.     

Analgesic dose-response relation in cervical epidural block

The relationship between the age and the spread of analgesia from different epidural anesthetic doses was examined by studying analgesic dose responses in cervical epidural analgesia. Two different anesthetic doses (5ml or 10ml) of 2% mepivacaine were injected into the cervical epidural space at a constant pressure (80mmHg) using an intravenous apparatus, and the spread of analgesia to pinprick was assessed. The significant correlation was found between the patients age and the number of spinal segments blocked (5ml:r = 0.8498, P < 0.01, 10ml:r = 0.5988, P < 0.01). The inverse linear relationship was found between the patients age and the segmental dose requirement (5ml:r = –0.6754, P < 0.01, 10ml:r = –0.5784, P < 0.01). Patients under 39 years of age showed a direct relationship between the dose injected and the number of spinal segments blocked, enabling prediction of the number of segments blocked with a given dose of local anesthetic. Doubling the epidural dose approximately doubled the number of spinal segments blocked. The analgesic dose-response relation in patients over 60 years of age differed from that in patients under 39 years of age and doubling the epidural dose did not double the number of spinal segments blocked. Progressively more extensive analgesia was obtained from a given dose of local anesthetic with advancing age. It was difficult to limit the extent of analgesia by injecting a smaller dose of local anaesthetic in the elderly.(Hirabayashi Y, Matsuda I, Inoue S et al.: Analgesic dose-response relation in cervical epidural block. J Anesth 2: 22–27, 1988)     

YL-1型颅内血肿穿刺针的临床应用

目的探讨YL-1型颅内血肿穿刺针对颅内疾病微创治疗的价值及临床应用。方法回顾性分析本院2005年3月至2007年3月应用YL-1型颅内血肿穿刺针治疗颅内疾病患者58例（高血压幕上脑出血38例;慢性硬膜下血肿12例;急性硬膜外血肿5例;脑积水2例;颅内张力性积气1例）评价YL-1型颅内血肿穿刺针其在颅内疾病的应用价值。结果经采用CT定位YL-1型颅内血肿穿刺针微创手术治疗颅内疾病患者58例,存活51例;死亡4例;术后放弃治疗3例。结论采用YL-1型颅内血肿穿刺针微创手术治疗颅内血肿、积水、积气是简单、有效的微创手术方法。