General anesthesia versus regional anesthesia

No distinct advantage is apparent between regional and general anesthesia when considering perioperative cardiac morbidity and mortality in peripheral vascular surgery. However, there is some evidence to support regional anesthesia over general anesthesia in an effort to optimize graft patency if the regional technique is extended into the postoperative period to provide neuraxial analgesia. An inadequate number of randomized, controlled trials have been conducted to determine whether regional or general anesthesia should be performed for carotid endarterectomy. The nonrandomized trials do support regional anesthesia by virtue of reductions in stroke, myocardial infarction, and death. A randomized, prospective trial is needed to verify these outcomes. The choice of technique does not appear to affect mortality in patients requiring hip fracture surgery, although Urwin et al. (29) reported less 1-month mortality in patients receiving regional anesthesia. General anesthesia has been associated with increased blood loss and thromboembolic complications in patients undergoing hip fracture repair. Epidural anesthesia has been shown to promote quicker return of bowel function postoperatively when the catheter has been sited at T12 or higher. Anastomotic breakdown in patients with epidural anesthesia/analgesia has rarely been reported. Most studies tend to show quicker return of bowel function when local anesthetics alone are administered epidurally.     

Brainstem anesthesia after peribulbar anesthesia

We report a case of pupilloplasty under peribulbar anaesthesia complicated by a brainstem anaesthesia requiring tracheal intubation and mechanical ventilation. Immediate outcome was good. We discuss the different mechanisms of this complication. The subarachnoidal (intrathecal) injection of local anaesthesic seems to be the most probable cause. The use of short needles should theoretically decrease the risk. Despite all these precautions, peribulbar anaesthesia should not be considered as an ordinary procedure.     

Chemonucleolysis. Peridural anesthesia versus general anesthesia

A prospective comparative study was carried out between two anesthetic techniques for chemonucleolysis. Patients were divided into 2 groups of 50 patients each. Group A were submitted to general anesthesia and group B to epidural anesthesia with 0.5% bupivacaine, 2% mepivacaine and buprenorphine. Group B was divided into 2 subgroups: in B1, buprenorphine was administered with the local anesthetics, while in B2 buprenorphine was administered postoperatively when pain appeared. Postoperative pain and side effects like anaphylaxis were evaluated. No anaphylactic reactions occurred. Severe lumbar pain appeared in 22% of patients in group A in spite of systematic analgesics, while group B lumbalgia was not severe in any case. Patients in subgroup B1 did not have pain during the 24 first hours and 47.8% of patients in subgroup B2 needed in most of the cases only a dose of buprenorphine. We conclude that epidural anesthesia is a good technique in chemonucleolysis and that the association bupivacaine, mepivacaine and buprenorphine provides a good postoperative pain relief.     

Intraoperative awareness during propofol anesthesia with epidural anesthesia

This report describes a case of awareness and recall during propofol anesthesia combined with epidural anesthesia in a 32-year-old woman scheduled for a resection of left ovarian tumor. After induction, anesthesia was maintained with propofol and epidural anesthesia. About one hour into maintenance, the patient was moving with haemodynamic signs suggesting inadequate analgesia. Immediately after extubation, the patient could recall the abdomen being touched during laparotomy. This case indicates that even if appropriate dose of propofol is administrated, intraoperative awareness may occur especially with inadequate analgesia.     

Caudal anesthesia combined with general anesthesia in comparison with general anesthesia in ambulatory circumcision

In 100 boys (5.9 +/- 3.2 years old) undergoing outpatient circumcision, analgesia was provided with 0.375% bupivacaine 1 ml/year of age by caudal injection (group I), administered after induction of general anesthesia. This group was compared with 100 boys (6.3 +/- 3.4 years old), who received only general anesthesia (group II). The puncture technique described was free of complications and the caudal blocks were 98% successful. There was a great difference with regard to the levels of general anesthesia: the average enflurane concentrations required to block autonomic reactions during surgical intervention was 1.3 vol% in group I and 2.7 vol% in group II. The amount of pethidine needed for perioperative pain relief was 8 mg (+/- 5.7) in 17/100 of group I and 17.3 mg (+/- 6.8) in 91/100 of group II. In addition, paracetamol was given in 10/100 of group I and 30/100 of group II. The boys in group I showed calm postoperative behavior. In both groups there were only slight differences in hemodynamic parameters. Of the parents who answered our questionnaire (50 answers to 60 questionnaires), 68% were amazed at the duration of analgesia. During the late postoperative period, in group I there was an almost total absence of vomiting (4%), with an associated rapid return to normal feeding. In 83% the effect of late postoperative analgesia worked so well that no subsequent analgesic was given. In 15% the pain relief lasted 6.3 +/- 2.5 h. The excellent postoperative pain relief produced by caudal anesthesia justifies its frequent use for children subjected to genital surgery.(ABSTRACT TRUNCATED AT 250 WORDS)     

Office-based anesthesia

Purpose

Ambulatory office-based anesthesia (OBA) is a relatively new but rapidly growing field. OBA requires a different approach than that used in the hospital, because there are unique considerations that must be recognized when administering anesthesia in a free-standing office facility. This review provides a summary of the important issues and aspects of safe patient care.

Methods

The Medline, Embase, Biological Abstract, Science Citation Index, and Healthstar databases were searched under the key words “office-based anesthesia” for relevant English language articles from 1966 to December 2008. Relevant publications were queried from governing institutions, such as the American Society of Anesthesiologists (ASA), as well as from colleges in various provinces across Canada.

Principal findings

Office-based anesthesia remains poorly regulated in many parts of Canada (and the US). Despite continuing concerns regarding patient safety, the rates of death and reported major complications for OBA appear to be very low, especially in accredited facilities. Multiple considerations for facility design, administration, and patient care need to be taken into account.

Conclusion

Appropriately so, an increasing number of provinces (Canada) and states (US) are beginning to regulate office-based facilities and require accreditation.     

Local anesthesia

In summary, many surgical procedures may be safely and comfortably performed utilizing regional anesthesia if only a few guidelines are followed as to choice and usage of local anesthetics. The success of a regional block will always be dependent upon correct needle placement by an experienced physician with good technical skills. However, the safety of the patient is not solely a function of experience. Modern local anesthetic preparations are reliable enough and simple enough to use that all physicians should be capable of achieving optimal patient safety at all times. If placed in a position which seems to require unfamiliar knowledge or expertise, the practitioner need only seek a consultant anesthesiologist for assistance. Plastic surgery is recognized as a specialty that frequently utilizes local anesthetics for office and outpatient procedures. The manner in which these drugs are used or abused determines their clinical reputation as well as that of the physician. It is important to promote a correct understanding of local anesthetic compounds, not only among ourselves as physicians, but also among our patients, who are becoming ever more knowledgeable of medical practice as time goes on.