Undetected central core disease myopathy in an infant presenting for clubfoot surgery

A 1-year-old child was scheduled for two stage bilateral clubfoot surgery. Preoperative evaluation was normal and total intravenous anesthesia with a continuous sciatic nerve block was performed. Two months later, before the second clubfoot correction, a hip subluxation was evident suggesting a provisional diagnosis of neuromuscular disease. Anesthesia was identical, except that a femoral nerve block, necessary to permit a diagnostic muscle biopsy was performed. The perioperative course was uneventful but result of the muscular biopsy was surprising in that central core disease was diagnosed. Although congenital myopathies of all grades and severity exist, they are often mild and underestimated. Patients affected by central core disease are considered susceptible to malignant hyperthermia. Because a high prevalence of myopathic changes is reported in children undergoing clubfoot surgery, anesthesiologists must take precautions including a hightened awareness of these events and a high index of suspicion.     

A prospective survey of postoperative nausea and vomiting with special regard to incidence and relations to patient characteristics, anesthetic routines and surgical procedures

We performed a prospective study on 421 patients subjected to routine general-, orthopaedic-, urologic-, gynecological and paediatric surgery to estimate the current incidences of nausea and vomiting during the first 24 hours after surgery.
The overall incidences of postoperative nausea or vomiting were 17% and 28%, respectively. Postoperative emetic symptoms were not related to age in adults. Women had more often emetic symptoms than men ( P <0.01). In general, opiate premedication was more frequently associated with postoperative nausea and vomiting than benzodiazepines ( P <0.01), but in otherwise comparable subgroups of patients undergoing major surgery, this difference was not confirmed. Balanced general anaesthesia caused more nausea (23%) and vomiting (53%) than face-mask anaesthesia (13% and 15%, respectively) or regional blocks (12% and 7%, respectively) ( P <0.001). There was a positive correlation between the duration of anaesthesia and the incidence of postoperative emetic symptoms ( P <0.001). The incidences of postoperative nausea and vomiting after abdominal surgery were 23% and 58% respectively. Corresponding figures for orthopaedic surgery were 25% and 34%, other kinds of extra-abdominal surgery 18% and 32% and for laparoscopy 21% and 25%. After minor gynecological-, urological-and paediatric surgery the incidences were less than 20%.
In conclusion female gender, balanced anaesthesia, lengthy duration of anaesthesia, and abdominal and orthopaedic operations appeared to be most frequently associated with postoperative emetic symptoms.     

Shorter discharge time after regional or intravenous anaesthesia in combination with laryngeal mask airway compared with balanced anaesthesia with endotracheal intubation

BACKGROUND AND OBJECTIVE: The efficiency of operating room times can be significantly improved using rapid changes between operative procedures. We performed a retrospective analysis using electronic anaesthesia charts that compared anaesthesia-related times between the three most frequently performed types of anaesthesia (for orthopaedic surgery) to evaluate the potential for a quicker turn-around between cases. METHODS: A total of 5614 anaesthetic procedures in trauma-related orthopaedic surgery were performed from 1997 to 1999. All were documented with an automatic record-keeping system. Data were compared for intravenous anaesthesia with the laryngeal mask airway, balanced anaesthesia with tracheal intubation and regional anaesthesia. The primary outcome measure was the time needed for emergence from anaesthesia after the end of surgery. Statistical evaluation was performed with matched triples for all three types of anaesthesia (155 triples for ambulatory surgery, 249 triples for in-patient care). RESULTS: For ambulatory surgery, the induction time was significantly shorter for general anaesthesia (23.7 min for intravenous anaesthesia, 22.7 min for balanced anaesthesia techniques) compared with regional anaesthesia (27.2 min). The time from the end of the surgical procedure to transfer of the patient out of the operating room was shortest for regional anaesthesia (6.3 min) compared with intravenous anaesthesia (9.0 min) and balanced anaesthesia (12.5 min) techniques. Results were comparable for in-patients: regional anaesthesia required significantly longer for its induction, but less time for patient discharge from the operating room. CONCLUSIONS: The use of a regional anaesthesia technique or one involving intravenous anaesthesia in combination with the laryngeal mask airway may lead to a reduction in discharge time compared with a balanced anaesthesia technique with endotracheal intubation. Thus, improved use of resources may be achieved.     

Anaesthetic practice and postoperative pulmonary complications

The aim of this study was to identify risk factors associated with postoperative pulmonary complications. The influence of the anaesthetic technique was evaluated (i.e. general contra regional anaesthesia and long contra intermediately acting muscle relaxants (pancuronium and atracurium)) taking into account the patient's age, the presence or absence of chronic obstructive lung disease (preoperative risk factors), the type of surgery and the duration of anaesthesia (perioperative risk factors). Seven thousand and twenty-nine patients undergoing abdominal, urological, gynaecological or orthopaedic surgery were included in the study. A total of 290 patients (4.1%) suffered from one or more postoperative pulmonary complications. Six thousand and sixty-two patients received general anaesthesia and 4.5% of these had postoperative pulmonary complications. Of the patients admitted to major surgery receiving pancuronium, 12.7% (135/1062) developed postoperative pulmonary complications, compared to only 5.1% (23/449) receiving atracurium (P < 0.05). When stratified for type of surgery and duration of anaesthesia, conventional statistics showed no difference between pancuronium and atracurium as regard postoperative pulmonary complications. However, a logistic regression analysis indicated that long-lasting procedures involving pancuronium entailed a higher risk of postoperative pulmonary complications than did other procedures. In patients having regional anaesthesia, only 1.9% (18/967) developed postoperative pulmonary complications (P < 0.05 compared to general anaesthesia). However, when stratified for type of surgery there was a significantly higher incidence of postoperative pulmonary complications only in patients undergoing major orthopaedic surgery under general anaesthesia, 11.5% compared to 3.6% in patients given a regional anaesthesia.(ABSTRACT TRUNCATED AT 250 WORDS)     

Regional Anaesthesia in Paediatric Surgery

The use of regional anaesthesia in paediatric surgery remains controversial although the pharmacological and technical aspects, even in this age group, have been described. Many authors regard regional anaesthesia as contra-indicated, and consequently general anaesthesia is preferred in paediatric surgery. In the present study regional anaesthesia was used in the form of supraclavicular, interscalene brachial plexus blockade, axillary brachial plexus blockade, lumbar epidural and spinal blockade in altogether 199 patients in the paediatric age group. Surgically excellent or satisfactory analgesia was achieved in 92-100% of the blocks. No complications were observed.     

Electromyography nerve conduction velocity evaluation of children with clubfeet

Neurologic deficit has been implicated as a possible etiology for clubfoot and a cause for recurrent deformity in patients who have undergone clubfoot surgery. In the study reported here, we wanted to determine if clubfoot patients with peroneal weakness had any neurologic deficits on electromyography nerve conduction velocity (EMG-NCV) studies before surgery and if there was any association between neurologic deficit and clubfoot recurrence. We reviewed the EMG-NCV studies of 36 patients involving 57 cases of idiopathic clubfoot and recurrence of the deformity or muscle weakness. In the clubfoot patients with weak peroneal muscle and no prior surgical history, 45% of the studies were interpreted as normal, 20% as neuropathic, 15% as mixed myopathic and neuropathic, 10% as radicular, and 10% as myopathic. In the clubfoot patients with recurrence after clubfoot repair surgeries, 57% had abnormal EMG-NCV studies. Specifically, peroneal mononeuropathy was the most common disorder (41% of clubfoot patients treated surgically). Awareness of a significant incidence of neurologic deficit may help in preoperative planning by indicating that ultimately a tendon transfer may be necessary to obtain a plantigrade foot.     

Incidence of malignant hyperthermia reactions in 2,214 patients undergoing muscle biopsy

To détérmine the incidence of malignant hyperthermia (MH) reactions after trigger-free anaesthesia in a large population of MH-susceptible (MHS) patients, the charts of 2,214 patients who underwent elective muscle biopsy for malignant hyperthermia were reviewed. Either general or regional anaesthesia with non-triggering drugs was used. For general anaesthesia, the trachea was intubated in the absence of muscle relaxants. The halothane/caffeine contracture test was performed on the biopsied muscle. Suspected MH reactions were identified according to their site of occurrence (in the operating room, recovery room or ward). Ninetyseven percent of patients received a general anaesthetic; 3% received a regional anaesthetic or field block. Of the 2214 patients whose muscles were biopsied, 1082 patients were biopsy-positive for MH. Five patients in whom MH reactions were diagnosed in the recovery room were all subsequently proved to be biopsy-positive for MH. Four of the five received intravenous dantrolene as part of their therapy; the fifth received only symptomatic therapy as parenteral dantrolene was not commercially available. All patients recovered complétély from their reactions. We conclude that the incidence of MH reactions in biopsy-positive patients who receive a trigger-free anaesthetic for minor surgery is small (0.46%, (0.15– 1.07%, 95% CI)). These reactions occur in the immediate postoperative period.     

Anaesthesia for Sturge-Weber syndrome.

A 6-month-old boy with Sturge-Weber syndrome was scheduled for congenital glaucoma and left buphthalmus surgery. Physical examination revealed haemangioma throughout the right trigeminal nerve, congenital glaucoma, left megalocornea and bilateral buphthalmus. Examination of the eye was performed under general anaesthesia, was followed 2 days later by trabeculotomy. No premedication was given to the patient. After induction of anaesthesia with halothane, O2 and N2O muscle relaxation was achieved with atracurium and he was intubated gently. No difference was observed in vital signs during surgery. At the end of the operation he was given oxygen 100% and extubated, muscle relaxant reversal was with atropine and neostigmine. No complication was observed in the post-operative period.     

Peripheral nerve block in orthopaedic surgery: multicentric evaluation of practicing professionals and impact on the activity of the recovery room

Objectives

Since the last national survey on evaluation of professional practice in France, many peripheral nerve blocks techniques were developed. The aim of this study was to assess the place of such techniques and their impact on the stay in recovery room after orthopaedic surgery.

Study design

Prospective, multicentric study.

Patients and methods

Consecutive patients receiving a regional anaesthetic technique for orthopaedic surgery over a 15-day period were included in this multicenter study (four private clinics, two non-university and three university hospitals). Characteristics of blocks, duration of stay and activity of nurses in post-anaesthetic care unit (PACU) were recorded for each patient.

Results

A total of 289 blocks performed in 283 patients were analyzed. A regional anaesthetic technique was performed alone or associated with a light sedation (58 and 8% respectively) or with a general anaesthesia (44%). A continuous peripheral nerve block (mainly for femoral and iliofascial blocks) was performed in 25% of patients, mostly in university hospital and private clinics (35 and 26% respectively), but only in 3% of cases in non-university hospital. Mean duration of PACU stay was 64 ± 67 minutes. This time was longer when regional anaesthesia was associated to or performed after general anaesthesia. Workload of nurses was a simple supervision in 47% of the cases (in 61% of patients receiving regional anaesthesia alone vs 21% in those with general anaesthesia, p < 0.05).

Conclusion

This survey confirms that peripheral nerve block became widely used in orthopaedic surgery. This decreases the medical workload in PACU, especially for distal upper limb surgery. Regional anaesthetic techniques must be well taught during formation cursus of residents.     

Anaesthetic management of two paediatric patients with Hecht–Beals syndrome

We undertook the anaesthetic management of two children with Hecht-Beals syndrome for orthopaedic surgery under general anaesthesia. Both patients had arachnodactyly, kyphoscoliosis, and multiple congenital joint contractures, but limited mandible excursion was not obvious preoperatively in either, although mental retardation made it difficult for them to cooperate with mouth examination. They had no apparent difficulties with their mouths in daily activities. The anaesthesia records of one patient showed that intubation had been difficult in an earlier procedure. The other patient also had a history of difficult intubation, with slight tearing of the corners of her mouth during an intubation procedure. During slow induction of general anaesthesia with sevoflurane, face mask ventilation was easily performed. We attempted to visualize the larynx under anaesthesia with muscle relaxation, but we were unsuccessful because of the limited mouth opening. After several trials, blind oral intubations were fortunately successful in both patients. There were no postoperative problems with the airway.     

Neuraxial anaesthesia in paediatrics

Neuraxial anaesthesia is a valuable aid in the practice of paediatric anaesthesia. Spinal and epidural blockade are used as either the sole anaesthetic or as an adjunct to general anaesthesia, and often confer significant postoperative analgesia. Caudal epidural anaesthesia is used extensively for lower abdominal, urological and orthopaedic procedures in the setting of outpatient surgery. Lumbar and thoracic epidural infusions via a catheter can provide analgesia for chest and upper abdominal procedures. Thoracic paravertebral blocks provide analgesia equivalent to thoracic epidurals but with fewer side effects. Their use in thoracic surgery have helped reduce the incidence of chronic thoracotomy pain. Major complications related to neuraxial catheter placement are uncommon in paediatric anaesthesia, even though block placement is typically after the patient is anaesthetized to ensure immobility during puncture. Available evidence suggest that it is safe to place regional blocks in children during general anaesthesia. Ultrasound is an excellent imaging modality for identifying the dura mater as the dura appears highly echogenic on ultrasound scans. Ultrasound imaging help estimate the location and level of spinous interspaces and may be useful in children with obesity, prior surgical instrumentation or scoliosis. The use of the ultrasound for real-time visualization during paediatric neuraxial blocks provides an opportunity for observing final catheter position or confirming successful injection into the epidural space.     

Neuraxial anaesthesia in paediatrics

Neuraxial anaesthesia is a valuable tool in the practice of paediatric anaesthesia. Spinal and epidural blockade are used for a variety of surgical cases as the sole anaesthetic or as an adjunct to general anaesthesia, and confer significant postoperative analgesia. Caudal epidural anaesthesia is used extensively for lower abdominal, urological, and orthopaedic procedures in the setting of outpatient surgery. Lumbar and thoracic epidural infusions via a catheter can provide analgesia for chest and upper abdominal procedures. The potential complications associated with neuraxial anaesthesia can be minimized by prudent technique and careful management. The use of the ultrasound for real-time visualization during paediatric neuraxial blocks may improve safety, success rate, and pain control after surgery.     

Intravenous regional anaesthesia for lower limb orthopaedic surgery.

Intravenous regional anaesthesia in lower limb orthopaedic surgery has rarely been reported. A prospective series of 50 orthopaedic procedures performed with prilocaine is presented. In over 90% of patients excellent anaesthesia was obtained.     

Regional blocks in orthopaedics

Acute postoperative pain management has played a significant role in decreased hospital stay and has been recognized to have a positive effect on functional recovery and patient satisfaction. Orthopaedic surgery is an expanding surgical specialty with a potentially difficult patient population. Regional anaesthesia is becoming increasingly popular as it offers several advantages over general anaesthesia. The aim of analgesic protocols is not only to reduce pain intensity but also to decrease the incidence of side-effects from analgesic agents and to improve patient comfort. Moreover, adequate pain control is a prerequisite for the use of rehabilitation programmes to accelerate functional recovery from orthopaedic surgery. Recently there has been resurgence in the use of regional anaesthesia as anaesthetists are better equipped with advanced techniques for nerve localization and visualization of needle and local anaesthetic spread hence can prevent side effects secondary to needle misplacement with ultrasound guidance. The use of peripheral nerve blocks has been associated with earlier discharge in ambulatory orthopaedic surgery when compared to general anaesthesia and neuraxial blockade. This article discusses the advantages and limitations of regional anaesthesia for perioperative pain management and various peripheral nerve blocks and catheter techniques used for commonly performed orthopaedic procedures. It also briefly mentions the recent advances in nerve localization techniques. Increased knowledge, training and practice in regional techniques has the benefit of improving analgesia and mobilization, shortened hospital stay and improving overall quality of care. Moreover, increased efficiency and decreased length of hospital stay have positive cost implications.     

Carotid endarterectomy under cervical epidural anesthesia. Analysis of neurologic manifestations

Carotid endarterectomy can be complicated by neurological events due to different mechanisms. Monitoring cerebral function is difficult under general anaesthesia. By contrast, the monitoring of awareness and neurological deficit is very easy under regional anaesthesia. The aim of this study was to assess the requirement for arterial shunting during endarterectomy performed under cervical epidural anaesthesia, to analyse the neurological events and to compare the value of clinical and electroencephalographic monitoring. Sixty-four patients were included in this study. Cervical epidural anesthesia was performed with 0.375% bupivacaine and 100-150 micrograms fentanyl. In 19 high risk patients, a one-channel electroencephalographic filter processor (Cerebral function monitor, Critikon) was placed over the affected hemisphere. Before surgery, it was estimated, on angiographic and Doppler data, that 18 patients needed an arterial shunt for carotid clamping. An arterial shunt was in fact inserted during surgery in only four patients, because of cerebral ischaemia after carotid clamping. Transient obnubilation was observed during carotid clamping in three other patients; it disappeared on unclamping in two, and on increasing blood pressure in the third. An additional patient suffered from a very short loss of awareness after declamping, due to cerebral embolism. The cerebral function monitor never documented false positive results, but failed to detect one out of every five neurological events. Controlateral carotid occlusion and preoperative stroke were documented to correlate with peroperative neurological events. Cervical epidural anaesthesia, which maintains consciousness during surgery, reduced in high-risk patients the need for arterial shunting as well as that for the analysis of neurological events.     

Anaesthesia for caesarean section in a patient with syringomyelia and Arnold-Chiari type I malformation

A 37-year-old primiparous woman with syringomyelia and Arnold-Chiari type I malformation was scheduled to undergo elective caesarean section for a fetus in the breech presentation. Caesarean section was performed under general anaesthesia without complications; all we observed was an exaggerated response to atracurium. The patient was discharged home 7 days after the operation without neurological deterioration. General anaesthesia was chosen in this patient to avoid any spinal manipulation that could increase intracranial pressure or reduce intraspinal pressure and cause deterioration of neurological symptoms. Syringomyelia is a progressive myelopathy characterised by cystic degeneration within the spinal cord, which causes severe neurological deficits. The anaesthetic management is discussed.     

Myotonia congenita and regional anaesthesia with peripheral nerve stimulation: a case report

Myotonia congenita is a rare disorder caused by a defect in the skeletal muscle chloride channel function, which may cause sustained membrane depolarisation. We report a case regarding a 52-year-old man affected by this muscular pathology and scheduled for shoulder surgery that was performed under sedation and peripheral nerve block. The international literature does not elucidate clear preference toward a particular anaesthesia technique, but we believe that in this setting, regional anaesthesia and complete monitoring should be preferentially utilized when possible. In any case, the anaesthesia plan should be prudent and avoid exposure to known dangerous anaesthetics.     

Is preoperative haemoglobin testing justified in children undergoing minor elective surgery?

The need for preoperative haemoglobin determination before the administration of general anaesthesia to paediatric patients has long been an issue for debate. This study was undertaken to determine the value of routine preoperative haemoglobin testing in paediatric patients scheduled for minor surgery. Two thousand patients ages one month to 18 yr scheduled for minor surgery were studied. The patients were grouped according to age, Group I less than or equal to yr, Group II 1-5 yr, Group III greater than 5 yr. The charts of patients whose preoperative haemoglobin concentration (Hb) was less than 100 g.L-1 were reviewed at a later date to determine the course of their anaesthesia and surgery. Eleven patients, all of whom were greater than 5 yr (0.5%), had a Hb less than 100 g.L-1. Of these, three patients, 27%, had their surgery deferred, whereas the remaining eight patients, 73%, underwent anaesthesia and surgery without complications. The three patients who were deferred returned for uneventful anaesthesia and surgery following oral iron therapy. We conclude that healthy paediatric patients five years and older scheduled for minor surgery do not require routine Hb determinations. Furthermore, the low incidence of anaemia and low deferral rate of anaemic children, 1-5 yr of age, lead us to question the value of preoperative Hb testing in this age group.     

Neuraxial anaesthesia in paediatrics

Neuraxial anaesthesia is a valuable aid in the practice of paediatric anaesthesia. Spinal and epidural blockade are used as either the sole anaesthetic or as an adjunct to general anaesthesia, and often confer significant postoperative analgesia. Caudal epidural anaesthesia is used extensively for lower abdominal, urological and orthopaedic procedures in the setting of outpatient surgery. Lumbar and thoracic epidural infusions via a catheter can provide analgesia for chest and upper abdominal procedures. Major complications related to neuraxial catheter placement are uncommon in paediatric anaesthesia, even though block placement is typically after the patient is anesthetized. The use of the ultrasound for real-time visualization during paediatric neuraxial blocks provides an opportunity for observing final catheter position or confirming successful injection into the epidural space.     

A randomized trial of caudal block with bupivacaine 4 mg x kg-1 (1.8 ml x kg-1) plus morphine (150 microg x kg-1) vs general anaesthesia with fentanyl for cardiac surgery

BACKGROUND: Regional anaesthesia has been used effectively in paediatric patients undergoing cardiac surgery and is thought to be safe. METHODS: Thirty patients ASA physical status II-III undergoing scheduled palliative or corrective cardiac surgery, receiving premedication with midazolam and anaesthetic induction with sevoflurane, fentanyl and pancuronium were randomly allocated to two groups. In group 1, patients received bupivacaine 0.22% 4 mg.kg-1 (1.8 ml.kg-1) and morphine 150 microg x kg-1 by the caudal route. After a 20-min period for the block to take effect, sevoflurane 0.5-1.0% and fentanyl 5 microg x kg-1 were administered for maintenance of anaesthesia. In group 2, the anaesthetic technique was the same as in group 1, without a caudal block and fentanyl 25 microg x kg-1 was administered at the moment of surgical incision. RESULTS: Cardiovascular and haemodynamic responses of patients receiving caudal block showed minor variations during the 20-min period between caudal and general anaesthesia. Fentanyl requirements during surgery were lower (P = 0.001) in patients with caudal block than patients with general anaesthesia. Extubation time was shorter (P = 0.034) in the caudal group. Two patients in the general anaesthesia group and one in the caudal group died because of postoperative complications. CONCLUSIONS: Caudal block with bupivacaine 0.22% 4 mg.kg-1 (1.8 ml.kg-1) and morphine 150 microg x kg-1 was safe and effective for paediatric patients undergoing cardiac surgery. However, patients might have a better outcome with a reduction of morphine dosage and administration of a muscle relaxant of shorter duration of action than pancuronium.