USE OF SUCTION CATHETERS AS AN ALTERNATIVE TO TRACHEAL TUBES IN ADULTS

A 16-gauge suction catheter (i.d. 4.0 mm) was used to intubatethe trachea in two patients in whom the larynx was narrowedas a result of pathological lesions, and normal, small diametertracheal tubes were too short.     

EFFECT OF THORACIC AND ABDOMINAL PRESSURE CHANGES ON THE EPIDURAL SPACE PRESSURE

The effect of changes in superior and inferior vena caval pressureson the pressure in the epidural space was studied in fifteenunpremedicated patients and in five dogs. It was found thatthe epidural space, unlike the subarachnoid compartment hadtwo types of pressure oscillations during spontaneous respiration.A superior vena caval-like pattern was found in the cervico-thoracicregion, whereas an inferior vena caval-like pattern was themost frequent finding in the lumbar epidural space. Manoeuvresproducing a generalized increase of venous pressure raised theepidural pressure all along the spine. Manoeuvres raising thevenous pressure in the superior or in the inferior vena cavalsystem were accompanied by a preferential increase in the pressureof the cervical or in the lumbar epidural space. As a consequence,it is suggested that the epidural space, unlike the subarachnoidcompartment, presents some degree of functional compartmentalizationinto three zones: cervico-thoracic, lumbar and sacral. It ispostulated that changes in visceral cavity pressures can betransmitted to the epidural space directly, through the intervertebralforamina and indirectly via both vena cava and the cerebrospinalfluid. It is concluded that factors increasing intrathoracicor intra-abdominal pressures will raise epidural space pressureand, as a consequence, may favour the spread of anaestheticsinjected into the epidural space.     

THE ROLE OF OXYBUTYNIN IN SPINAL CORD INJURED PATIENTS WITH INDWELLING CATHETERS

Purpose

The long-term benefits of oral oxybutynin in spinal cord injured patients with indwelling catheters is unknown. We reviewed our experience with this population of men and present the results of our analysis.

Materials and Methods

A total of 109 male spinal cord injured patients at the Houston Veterans Affairs Medical Center have been treated with chronic indwelling catheters (80 transurethral and 29 suprapubic). Thirty-eight patients (35%) were identified as using oxybutynin on a regular basis. These patients were compared to those not using oxybutynin with regard to urodynamic parameters and upper tract deterioration. Specifically examined were bladder compliance, bladder leak point pressure, vesicoureteral reflux, hydronephrosis, urolithiasis, febrile urinary tract infections and serum creatinine greater than 2 mg./dl.

Results

The mean duration of indwelling catheter use was 11.9 years (12.4 without oxybutynin and 10.9 on oral oxybutynin). Of the 31 patients with normal compliance (greater than 20 ml./cm. water), 24 (77%) were using oxybutynin (p = 0.001). Bladder leak point pressures were abnormal (greater than 35 cm. water) in 5 of 32 patients (16%) on oxybutynin versus 34 of 60 (57%) without it (p <0.001). Hydronephrosis was present in 15 of 66 patients (23%) without oxybutynin versus 1 of 36 (3%) with oxybutynin (p = 0.009). Febrile urinary tract infections occurred in 4 of 35 patients (11%) versus 17 of 62 patients (27%) with or without oxybutynin, respectively (p = 0.077). No significant differences were found between the 2 groups with regard to reflux, renal scars, stones or elevated serum creatinine.

Conclusions

It appears that regular use of oxybutynin may be beneficial in spinal cord injured patients who require chronic indwelling catheters for bladder management. Our analysis reveals that patients who take oxybutynin regularly have better bladder compliance, lower bladder leak point pressures and less hydronephrosis. Until a prospective, randomized trial reveals contradicting outcomes, empiric use of oxybutynin in all spinal cord injured patients requiring chronic indwelling catheters seems justified.     

AN ANALYSIS OF THE PATHOLOGY OF 3003 APPENDICES

An analysis was made of 3003 appendices seen in a ten-year period (1969–1978) in the Dunedin Hospital Surgical Pathology Laboratory. Acute appendicitis was found to be a disease of the young, with 1385 (80%) cases out of 1711 occurring in patients less than 30 years of age. Faecaliths and lymphoid hyperplasia were found only in a very small percentage of acute appendicitis cases, and this lends further support to the hypothesis that acute appendicitis is a disease of western culture where the diet is low in cellulose. There was no seasonal predilection for acute appendicitis. of her pathological conditions were discussed and illustrated. More normal appendices and more of those exhibiting non-acute conditions were removed from females. The submission of appendices for histological evaluation is a most worthwhile procedure, with a significant yield of unexpected important information.     

RADIOLOGICAL EXAMINATION OF THE INTRATHECAL POSITION OF MICROCATHETERS IN CONTINUOUS SPINAL ANAESTHESIA

There have been few studies of the intrathecal position of spinalcatheters in continuous spinal anaesthesia. This prospectivestudy was designed to examine radiologically the intrathecalposition of 28-gauge spinal catheters. We studied the entryinto the subarachnoid space and the intrathecal position of68 spinal catheters. In 50%, the catheters passed in a cranialdirection, in 34% the catheters remained at the level of thepuncture site and in 16% the catheters were directed caudally.The intrathecal position of the catheters did not depend onthe level of the lumbar puncture (P = 0.6246), but was dependenton the position of the patient during insertion of the catheter(P = 0 0093), and on the depth of insertion (P = 0.0099). Ourstudy sug gests that patients should be in a sitting positionduring insertion of a subarachnoid microcatheter and that thedepth of insertion should not exceed 4cm. (Br. J. Anaesth. 1993;71: 803–806)     

肝门胆管癌44例治疗分析

目的 探讨肝门胆管癌的治疗.方法 回顾性分析我院2000～2005年收治的44例肝门胆管癌病人的临床资料.结果 本组手术治疗40例,手术切除率为42.5%(17/40),根治性切除8例(20%),姑息性切除9例(22.5%),单纯内引流、外引流各10例,3例仅行剖腹探查.4例病人合并肝叶切除,术后1例出现肝功能衰竭.未行肝叶切除病人无1例发生肝功能衰竭.结论 Bismuth-Corlette分型可指导手术方式选择,但能否切除取决于病期.黄疸较深且拟行较大肝叶切除术时应行术前减黄,可减少术后肝功能衰竭的发生.     

CHRONIC CANNULATION OF THE INTRADURAL OR EXTRADURAL SPACE IN THE RAT

An animal preparation has been developed to test therapeuticagents in the extradural and intradural spaces. Under anaesthesiaa hole was drilled in the penultimate lumbar vertebra of maleWistar rats and the appropriate space cannulated. The catheterwas tunnelled subcutaneously to emerge at the neck. There wasno spinal cord or meningeal reaction after 1 month. Cathetersremained patent for 3 months. The method of cannulation allowedfree rostral spread of drugs. Using plain 2% lignocaine, paralysisand anaesthesia of the hind limbs required an intradural volumeof 32±3 µlitre: the required volume on extraduralinjection was 46±2µlitre (P<0.01). Paralysisof all limbs required an intradural volume of 115 ±12µlitre.Respiratory arrest and death required a mean intradural volumeof 179±15µlitre. Present address, for correspondence: Department of Anaesthetics,University Hospital of Wales, Health Park, Cardiff CF4 4XW