Heart block following propofol in a child

We present the case of a nine-year-old boy afflicted with Ondine's curse, who developed complete atrioventricular heart block after a single bolus of propofol for induction of anaesthesia for strabismus surgery. Ondine's curse, the other name for congenital central hypoventilation syndrome, is characterized by a generalized disorder of autonomic function. Propofol has no effect on the normal atrioventricular conduction system in humans but it reduces sympathetic activity and can highly potentiate other vagal stimulation factors. Heart block has been documented after propofol bolus use in adults but, to our knowledge, not in children. It would appear that propofol is not a good choice for anaesthesia in congenital central hypoventilation syndrome.     

Splenic injury during abdominal surgery.

Of 237 splenectomies performed over a six-year period, 39 were necessitated by intraoperative injury. Capsular and hilar tears were predominant. All injuries were recognized at the time they occurred. The incidence of pulmonary complications and wound infections exceeded those for other categories of splenectomy and for these other abdominal operations without splenectomy. Although these complications were not fatal and the mortality was not increased, measures for avoidance of intraoperative splenic injury are indicated. These include knowledge of anatomic relationships and exercising cautious traction in operations on the upper part of the stomach and the splenic flexure of the colon, in reoperation in elderly people, or where there is suspicion of intrinsic splenic abnormality.     

Epidural block during general anesthesia attenuates urinary trypsin inhibitor excretion in lower abdominal surgery

Purpose. The aim of this study was to elucidate whether urinary trypsin inhibitor excretion differs between general anesthesia (GA) and epidural block during general anesthesia (EPI) in lower abdominal surgery. Methods. Sixteen women undergoing abdominal total hysterectomy were assigned to the GA and EPI groups. The GA group received propofol induction and maintenance with isoflurane, nitrous oxide, and vecuronium. The EPI group received epidural block, followed by propofol induction and maintenance with isoflurane and nitrous oxide. The levels of adrenocorticotropic hormone and cortisol during anesthesia and on postoperative days 1, 2, and 3, and the levels of urinary trypsin inhibitor in 12-h urine from the day of surgery to postoperative day 3, were measured. Results. As compared with the EPI group, the GA group had a higher level of adrenocorticotropic hormone at the completion of anesthesia, higher levels of cortisol at the completion of anesthesia and postoperative day 2, and higher excretion of urinary trypsin inhibitor on the day of surgery and postoperative days 1 and 2. Conclusion. The present results suggest that excretion of urinary trypsin inhibitor into the urine under epidural block during general anesthesia is lower than that under general anesthesia alone in lower abdominal surgery. This is probably due to the difference in endocrine response to surgery between the two types of anesthesia. Received for publication on August 26, 1998; accepted on March 16, 1999     

The lumbosacral epidural block: a modified Taylor approach for abdominal urologic surgery in children.

We describe the lumbosacral epidural approach in 97 children undergoing abdominal urologic surgical procedures. Due to the rudimentary spinous process of the first sacral vertebra and the less prominent sacral angle, an appropriate upward inclination of the Tuohy needle in the midline is always possible in infants and small children. A catheter was easily inserted in every case and the technique was shown to be useful and safe for providing adequate intraoperative and postoperative pain control.     

Muscle relaxation during abdominal surgery

A self-retaining surgical retractor has been modified by incorporating a strain gauge device linked to a digital display meter. This instrument is capable of continuously monitoring abdominal wall relaxation during surgery and should prove useful in a variety of routine and investigative procedures.     

超声引导下腹横肌平面阻滞在新生儿下腹部手术中的应用

目的观察超声引导下腹横肌平面(transversus abdominis plane,TAP)阻滞在新生儿下腹部手术中的麻醉效果。方法拟行下腹部手术的新生患儿30例,男19例,女11例,出生1~18d,体重2.8~4kg,ASAⅠ或Ⅱ级,按照随机数字表将患儿随机分为超声引导下TAP阻滞联合全身麻醉组(T组)和单纯全身麻醉组(G组),每组15例。T组患儿在超声引导下行双侧TAP阻滞,注入0.15%罗哌卡因0.5ml/kg。两组均采用静-吸复合麻醉,吸入3%七氟醚,持续泵注瑞芬太尼0.1~0.3μg·kg~(-1)·min~(-1),维持BIS值在50~60。记录患儿术中阿片类药物用量;入室后、切皮时和拔管后30min血浆皮质醇(Cor)浓度;苏醒时间,术后烦躁、呼吸抑制及需要补救镇痛情况。结果与G组比较,T组术中瑞芬太尼用量明显降低(P0.05)。与入室后比较,切皮时和拔管后30 min,G组血浆Cor浓度明显升高(P0.05);与G组比较,切皮时和拔管后30min,T组血浆Cor浓度明显降低(P0.05)。T组苏醒时间明显短于G组(P0.05)。G组有4例(27%)需要补救镇痛,3例(20%)呼吸抑制及4例(27%)躁动,T组无一例不良反应。结论超声引导下0.15%罗哌卡因TAP阻滞可以安全有效地用于全麻下新生儿患下腹部手术。     

Changes in respiratory mechanics during abdominal laparoscopic surgery in children.

We designed this study in order to measure the changes in respiratory mechanics during laparoscopic surgery in children. Ventilation parameters (Flow (Ví) and Peak Pressure (Pmax)) were measured and total respiratory system mechanics (resistance (Rrs) and compliance (Crs)) were derived using multiple linear regression analysis in 11 children aged 8 months to 11 years. The Pmax increased by 26.6% and the Rrs increased by 20.2% whilst the Crs decreased by 38.9% after pneumoperitoneum. These findings suggest that clinically important changes in respiratory mechanics occur as a result of the pneumoperitoneum produced during abdominal laparoscopic surgery.     

Heart block in patients after bariatric surgery accompanying sleep apnea

Backround: Heart block and bradycardia during sleep has been reported in patients with obesity. The occurrence of bradyarrythmias in patients after undergoing bariatric surgery has not been reported. Methods: Over a period of 6 months, 3 patients who underwent laparoscopic weight reduction surgery developed prolonged heart block during sleep. Clinical course and follow-up are presented. Results: All 3 patients were diagnosed with sleep apnea. For 2 of these patients this was a new diagnosis. The episodes of heart block coincided with their episodes of sleep apnea. During follow-up of at least 6 months, no patient has had any adverse consequences related to their nocturnal heart block. Conclusion: Heart block during sleep is sometimes seen in patients undergoing bariatric surgery. The cause is sleep apnea, which often is worsened in the postoperative state due to narcotic analgesics. These patients require treatment of their sleep apnea, not pacemakers.     

Improvement of diaphragmatic function by a thoracic extradural block after upper abdominal surgery

The effects on diaphragmatic function of a thoracic epidural block were assessed in 13 patients after upper abdominal surgery (UAS). Lung volumes and tidal changes in chest wall circumferences and gastric (delta Pgas) and esophageal (delta Pes) pressures were measured pre- and postoperatively. Volume displacement of the abdomen divided by tidal volume (delta VAB/VT) and delta Pgas/delta Pes were taken as indices of the diaphragmatic contribution to tidal breathing. These respiratory variables were obtained in the postoperative period, before and after epidural injection of 0.5% plain bupivacaine to achieve a block up to the T4 segment. UAS was constantly associated with a decrease in VT, delta VAB/VT, delta Pgas/delta Pes, and forced vital capacity (FVC). Epidural block was associated with an increase in VT, delta VAB/VT, and FVC. delta Pgas and delta Pgas/delta Pes returned to their preoperative values. It is concluded that: 1) diaphragmatic dysfunction observed after UAS is partially reversed by thoracic epidural block; and 2) that inhibitory reflexes of phrenic activity arising from the abdominal compartment (abdominal wall and/or viscera) could be involved in this diaphragmatic dysfunction.     

Heat conservation during abdominal surgery]

Intraoperative hypothermia is a major problem in anesthetic management. We compared the heat conserving effect of a forced air warming system (Bair Hugger, Augustine Medical Inc.) with that of a warming blanket. Sixteen patients undergoing abdominal surgery were studied. Patients were anesthetized with nitrous oxide and oxygen combined with epidural anesthesia. Patients received tympanic, rectal, bladder and core temperature monitorings. Patients were divided randomly to Bair Hugger group (BH, n = 8) or warming blanket group (WB, n = 8). Temperature were measured every one hour over three hours. The BH group showed significantly higher temperatures than WB group. Bair Hugger system is an efficient way to maintain intraoperative body temperature.     

Lung mechanics during upper abdominal surgery

Functional residual capacity (FRC) and breath-by-breath compliance of the respiratory system (Crs) were studied after induction of anaesthesia, after insertion of retractors and after wound closure in patients undergoing upper abdominal surgery via a subcostal (n = 8) or a midline (n = 8) incision. After anaesthesia induction the mean FRC was 1.6 +/- 0.3 l. In the subcostal incision group FRC did not change between the studied stages, but Crs fell after retractor placement from 51 +/- 3 to 43 +/- 5 ml/cmH2O (p less than 0.01). In the midline incision group FRC rose by 21% (p less than 0.01) when the retractors were inserted, but regained outset level after wound closure. Crs in this group did not change significantly after retraction, but after closure of the wound it fell to 44 +/- 6 ml/cmH2O, i.e. less (p less than 0.05) than the outset value (52.6 ml/cmH2O). FRC thus did not decrease in either group, but Crs fell by about 15%. The authors conclude that the known difference in postoperative pulmonary complications between midline vs. subcostal incisions is not caused by the studied intraoperative events.