Reinforcement of spinal anesthesia by epidural injection of saline: a comparison of hyperbaric and isobaric tetracaine

Purpose. An epidural injection of saline was reported to extend spinal anesthesia because of a volume effect. The aim of this study was to evaluate the influence of the baricity of spinal local anesthetics upon the extension of spinal anesthesia by epidural injection of saline. Methods. Forty patients undergoing elective lower-limb surgery were randomly allocated to four groups of 10 patients each. Group A received no epidural injection after the spinal administration of hyperbaric tetracaine (dissolved in 10% glucose). Group B received an epidural injection of 8 ml of physiological saline 20 min after spinal hyperbaric tetracaine. Group C received no epidural injection after spinal isobaric tetracaine (dissolved in physiological saline). Group D received an epidural injection of 8 ml of saline 20 min after spinal isobaric tetracaine. The level of analgesia was examined by the pinprick method at 5-min intervals. Results. The levels of analgesia 20 min after spinal anesthesia were significantly higher in hyperbaric groups than in isobaric groups [T5 (T2–L2) vs. T7 (T3–12)]. After epidural injection of saline, the levels of analgesia in groups B and D were significantly higher than in groups A and C. The segmental increases after epidural saline injection were 2 (0–3) in group B and 2 (1–7) in group D. Sensation in the sacral area remained 20 min after spinal block in one patient in group D; however, it disappeared after epidural saline injection. Conclusion. In this study, 8 ml of epidural saline extended spinal analgesia. However, there was no difference between the augmenting effect in isobaric and hyperbaric spinal anesthesia. We conclude that the reinforcement of spinal anesthesia by epidural injection of saline is not affected by the baricity of the spinal anesthetic solution used. Received for publication on March 11, 1999; accepted on December 13, 1999     

Immediate postoperative refeeding in orthopedic surgery is safe

The purpose of this retrospective study was to investigate the morbidity of immediate postoperative refeeding after orthopedic surgery. We included all the 1077 patients who underwent orthopedic surgery between January and December 2003 at our military teaching hospital. General anesthesia was performed in 37% of the patients (n = 398), 24% (n = 259) had combined general and regional anesthesia, and 39% (n = 420) had isolated regional anesthesia (spinal anesthesia and/or peripheral regional anesthesia). After surgery, each patient was allowed free access to solid and liquid food immediately after discharge from the postanesthetic care unit. Although no systematic nausea and vomiting prophylaxis was performed, only 7% (n = 75) of the patients had postoperative nausea and vomiting during the first 48 h. Moreover, neither deglutition trouble nor aspiration syndrome was observed during that period. Our results suggest that immediate postoperative refeeding after orthopedic surgery is safe, does not increase postoperative nausea and vomiting, and probably increases the comfort of patients.     

Different anesthesia methods for laparoscopic cholecystectomy

Objectives

The aim of the study was to compare the possibility of performing laparoscopic cholecystectomy using two different anesthesia procedures (spinal anesthesia versus general anesthesia).

Methods

The study included 68 patients with symptoms of cholelithiasis examined in the 309th Hospital of PLA from 2006 to 2009. Patients were randomly selected to undergo laparoscopic cholecystectomy with low tension pneumoperitoneum with CO₂ under general anesthesia (n=33) or spinal anesthesia (n=35). The study used propofol, fentanyl, rocuronium, sevoflurane and tracheal intubation for general anesthesia and hyperbaric 15?mg bupivacaine and 20???g fentanyl were used to achieve a sensorial level of T₃ for spinal anesthesia. Intraoperative parameters, postoperative pain, complications, recovery, patient satisfaction and cost were compared between both groups.

Results

All surgical procedures were completed with the chosen method with the exception of one case, in which spinal anesthesia was converted to general anesthesia. Shoulder pain was significantly less frequent in the spinal anesthesia group (6%) compared with the general anesthesia group (24%). The level of pain at 2, 4, and 6?h after the procedure under spinal anesthesia was significantly lower than that under general anesthesia. At 12?h both groups had the same evaluation in the visual analogue scale. In the spinal anesthesia group all patients recovered 6?h after surgery, while patients in the general anesthesia group spent more time in recovery. All patients were discharged from hospital after 24?h. In the postoperative evaluation all patients were satisfied with the spinal anesthesia and would recommend this procedure, while only 78.9% of patients were very satisfied in the general anesthesia group. The cost of spinal anesthesia was significantly lower than that of general anesthesia.

Conclusions

Laparoscopic cholecystectomy with low pressure pneumoperitoneum with CO₂ can be safely performed under spinal anesthesia. Spinal anesthesia was associated with an extremely low level of postoperative pain, better recovery and lower cost than general anesthesia.     

Intravenous lidocaine simultaneously infused with sufentanil to accelerate gastrointestinal function recovery in patients after thoracolumbar surgery: a prospective,randomized, double-blind controlled study

Purpose

Postoperative gastrointestinal dysfunction is one of the common complications of surgery, especially after surgery for a thoracolumbar spinal fracture. Intravenous lidocaine is a potential method to improve postoperative gastrointestinal function in surgical patients, reduce opioid use and shorten hospital stays. The purpose of this study is to explore the effect of intravenous lidocaine on the recovery of gastrointestinal function in patients after thoracolumbar surgery.

Methods

In this study, 48 eligible patients undergoing elective thoracolumbar spine fractures resection and internal fixation surgery were enrolled to receive intravenous injections of lidocaine in different concentrations during the perioperative period. Patients were randomly divided into three groups: control group (group A), low concentration of lidocaine group (group B) and high concentration of lidocaine group (group C), 16 patients in each group. First postoperative exhaust time, numbers of bowel sound at preoperative and postoperative 3, 6, 12, 24 h, pain scores at postoperative 0, 3, 6, 12, 24, 48 h, total sufentanil use in PACU and perioperative periods, postoperative hospital stay and analgesic remedy within postoperative 48 h were recorded and compared. The primary endpoints include: the time of first flatus passage after the operation, the number of bowel sounds per minute counted with stethoscope at 30 min before anesthesia induction and at 3, 6, 12 and 24 h postoperative. The secondary endpoints included: the pain scores at PACU (after entering into PACU), 3, 6, 12, 24 and 48 h postoperative, the amount of sufentanil administrated by intravenous push during operation and the numbers of patients needed rescuing sufentanil in PACU, and the numbers of patients needed administration of gastric motility drugs or non-steroidal analgesics at ward within 48 h postoperation, length of hospital stay (from the first day after surgery to discharge from hospital) and the incidence of adverse reactions.

Results

Compared with group A, the first postoperative exhaust time in group B and C occurred much earlier (23.3 ± 11.0 h vs. 16.0 ± 6.6 h, 16.6 ± 5.1 h, P < 0.05). Compared with preoperation, the numbers of bowel sound significantly increased at 24 h postoperatively in group B, while group B at 6 h and group C at 6 and 24 h postoperatively had significantly more active bowel sounds compared to group A (P < 0.05). There were no remarkable differences in VAS scores within 12 h postoperatively among three groups, and however, significantly lower VAS scores were found at 12, 24 and 48 h postoperatively in group C when comparing to Group A (p < 0.05). There was no statistical significance in the incidence of postoperative flatulence and nausea and vomiting, the number of patients needed rescuing sufentanil in PACU, the length of postoperative hospital stay and the number of patients requiring non-steroidal analgesics at ward within 48 h postoperation.

Conclusions

Intravenous lidocaine infusion together with patient-controlled analgesia of sufentanil expedited the early recovery of gastrointestinal function and improved analgesic quality of sefentanyl in patients undergoing thoracolumbar surgeries.

     

Hemodynamic effects of a right lumbar-pelvic wedge during spinal anesthesia for cesarean section

Background

Aortocaval compression is a major cause of maternal hypotension. A randomized controlled trial was designed to determine the effectiveness of a mechanical intervention using a right lumbar–pelvic wedge in preventing hypotension after spinal anesthesia for cesarean delivery.

Methods

Eighty healthy women undergoing elective cesarean section were randomly allocated immediately after spinal blockade to either a lumbar–pelvic wedge positioned under the right posterior–superior iliac crest (Wedge group, n = 40) or the complete supine position (Supine group, n = 40). Hemodynamic values, vasopressor consumption and adverse effects were collected during the surgical procedure. Hypotension was defined as a reduction in systolic blood pressure of 25% from baseline. Patient allocation, management and data collection were performed by a single unblinded anesthetist.

Results

There was no difference in the incidence of hypotension between the two groups (42.5% vs. 50%, P = 0.51). During the first 5 min, blood pressure decreased less in the Wedge group. There were significant differences in median [interquartile range] vasopressor requirements between the Wedge group and the Supine group (1 [0–2] vs. 3 [1–4] mg, P < 0.01) and in nausea during the procedure (6 vs. 22 patients, P < 0.01).

Conclusion

In our study population the use of right lumbar–pelvic wedge was not effective in reducing the incidence of hypotension during spinal anesthesia for cesarean section. Patients in whom the wedge was used had higher systolic blood pressure values during the first 5 min of anesthesia and fewer episodes of nausea. The risk of hypotension remains substantial.     

Omission of fentanyl during sevoflurane anesthesia decreases the incidences of postoperative nausea and vomiting and accelerates postanesthesia recovery in major breast cancer surgery

Purpose Our purpose was to investigate the effect of omission of fentanyl during sevoflurane anesthesia on the incidences of postoperative nausea and vomiting and on postanesthesia recovery in female patients undergoing major breast cancer surgery. Methods Female patients (American Society of Anesthesiologists [ASA] physical status [PS] class I-II; age, 28–84 years) undergoing major breast cancer surgery were randomized to one of two anesthesia maintenance groups: sevoflurane-fentanyl anesthesia (SF; n = 25) or fentanyl-free sevoflurane anesthesia (S; n = 26). All patients were administered with propofol 2 mg·kg⁻¹ intravenously for anesthesia induction, a laryngeal mask airway was placed, and they received rectal diclofenac and local infiltration anesthesia. Anesthesia was maintained with sevoflurane in oxygen-air and they breathed spontaneously. The patients in group SF received fentanyl 0.1 mg intravenously and those in group S received normal saline during anesthesia. Results Group SF revealed higher incidences of postoperative nausea (68% vs 27%) and vomiting (32% vs 8%) in the first 24 postoperative hours than group S. The median (25th–75th percentile) length of time from postanesthesia care unit (PACU) admission to ambulation was significantly longer in group SF (n = 23) at 195 min (158–219 min), than in group S, at 141 min (101–175 min). Two patients in group SF could not walk during the PACU stay. Conclusion Omission of fentanyl during sevoflurane anesthesia, combined with diclofenac and local infiltration anesthesia, decreases the incidences of postoperative nausea and vomiting and accelerates postanesthesia recovery in patients undergoing major breast cancer surgery. This work was presented in part at the 49th Congress of the Japanese Society of Anesthesiologists, in Fukuoka.     

Postoperative analgesia after spinal blockade in infants and children undergoing cardiac surgery

The aim of this prospective, randomized, controlled clinical trial was to define the opioid analgesic requirement after a remifentanil (REMI)-based anesthetic with spinal anesthetic blockade (SAB+REMI) or without (REMI) spinal blockade for open-heart surgery in children. We enrolled 45 patients who were candidates for tracheal extubation in the operating room after cardiac surgery. Exclusion criteria included age <3 mo and >6 yr, pulmonary hypertension, congestive heart failure, contraindication to SAB, and failure to obtain informed consent. All patients had an inhaled induction with sevoflurane and maintenance of anesthesia with REMI and isoflurane (0.3% end-tidal). In addition, patients assigned to the SAB+REMI group received SAB with tetracaine (0.5-2.0 mg/kg) and morphine (7 mug/kg). After tracheal extubation in the operating room, patients received fentanyl 0.3 mug/kg IV every 10 min by patient-controlled analgesia for pain score = 4. Pain scores and fentanyl doses were recorded every hour for 24 h or until the patient was ready for discharge from the intensive care unit. Patients in the SAB+REMI group had significantly lower pain scores (P = 0.046 for the first 8 h; P =0.05 for 24 h) and received less IV fentanyl (P = 0.003 for the first 8 h; P = 0.004 for 24 h) than those in the REMI group. There were no intergroup differences in adverse effects, including hypotension, bradycardia, highest PaCO(2), lowest pH, episodes of oxygen desaturation, pruritus, and vomiting.     

Effect of Anesthetic Methods on Cerebral Oxygen Saturation in Elderly Surgical Patients: Prospective, Randomized, Observational Study

Background

Intraoperative cerebral oxygen desaturation was reported to be associated with postoperative cognitive dysfunction in elderly patients. The effect of the anesthesia method on regional cerebral oxygen saturation (rSO₂) is still a question under debate. The purpose of this study was to compare the effects of three common anesthesia methods on intraoperative rSO₂ changes in elderly patients.

Methods

In this prospective randomized clinical trial, 87 patients scheduled for elective transurethral prostatectomy were allocated to receive general inhalational anesthesia (GA group, n?=?30), spinal anesthesia (SA group, n?=?28), or spinal anesthesia plus sedation with midazolam (SA+S group, n?=?29).

Results

The numbers of patients showing a decrease in rSO₂ below the baseline value were higher in the SA (92.9?%) and SA+S (100?%) groups than in the GA group (33.3?%). The number of patients with a ≥50?% decrease in rSO₂ below baseline was greater in the SA+S (31.0?%) group than in the GA (0?%) or SA (3.6?%) group. During surgery, patients subjected to general anesthesia had higher rSO₂ than those with spinal anesthesia. Blood pressures and heart rates were similar in three groups except 5 and 10?min after anesthesia. Intraoperative SpO₂ was higher in the GA group than in the two spinal anesthesia groups.

Conclusions

Spinal anesthesia is associated with more frequent cerebral desaturation than general anesthesia; and it was aggravated when combined with midazolam sedation. The cerebral effects of anesthesia should be considered when managing high-risk elderly patients.     

Adding intrathecal morphine to unilateral spinal anesthesia results in better pain relief following knee arthroscopy

Purpose  Intrathecal morphine is administered to provide profound and prolonged analgesia, and to treat acute postoperative pain. We compared the effectiveness of hyperbaric bupivacaine alone and in combination with morphine for unilateral spinal anesthesia in patients undergoing knee arthroscopy. Methods  Sixty patients were randomly allocated to two groups to receive either 1.2 ml (6 mg) of 0.5% hyperbaric bupivacaine (group B; n = 30) or 1.2 ml of 0.5% hyperbaric bupivacaine containing 0.16 mg of morphine (group BM; n = 30). Spinal block was assessed by pinprick and a modified Bromage scale and compared between the operated and nonoperated sides. Visual analog scale (VAS) values, duration of analgesia, and total analgesic requirement of patients were recorded. Results  Patients in group BM had significantly lower VAS values on movement at 30 min and at 2, 4, 6, and 12 h postoperatively (P < 0.05 and P < 0.001, P < 0.001, P < 0.001, and P < 0.05, respectively). The total analgesic requirement in the first 24 h after surgery was significantly higher in group B (P < 0.001). Patients in group BM had a significantly longer duration of analgesia in the first 24 h postoperatively (P < 0.001). Motor blockade of the operated limb in group BM was similar to that in group B (P > 0.05), and motor blockade of the nonoperated limb in group BM was also similar to that in group B (P > 0.05). Conclusion  We conclude that unilateral spinal anesthesia with hyperbaric bupivacaine plus 0.16 mg morphine is preferable to hyperbaric bupivacaine alone with respect to analgesic requirement, duration of analgesia, and VAS values.     

Early Oral Feeding Versus Traditional Postoperative Care After Abdominal Emergency Surgery: A Randomized Controlled Trial

Background

Early oral feeding (EOF) has been demonstrated to be safe and beneficial after abdominal elective surgery. The aim of this randomized controlled trial is to assess the safety and benefits of EOF compared to traditional postoperative care (TPC) after abdominal emergency surgery.

Methods

Patients assigned to the EOF group commenced a soft diet within 24 h after surgery. In the TPC group, a liquid diet was commenced upon passage of flatus or stool and then advanced to soft food. The primary endpoint was the complication rate. Secondary endpoints were severity of complications, mortality, gastrointestinal leaks, surgical-site infection, reoperation, diet intolerance, time to first flatus and stool, amount of food intake, postoperative discomfort, hospital stay, weight loss at the 15th postoperative day and incisional hernias.

Results

A total of 295 patients assigned to EOF (n = 148) or TPC (n = 147) were analyzed. No significant differences were seen in the complications rates (EOF 45.3 % vs. TPC 37.4 %; p = 0.1). There was a significantly higher rate of vomiting with EOF (EOF 13.5 % vs. TPC 6.1 %; p = 0.03), with no differences in nasogastric tube reinsertion. EOF patients’ food intake was proportionally lower for the first three meals than that of TPC patients (p < 0.01). Postoperative discomfort survey revealed more hunger in the TPC group (p < 0.01). There were no differences in postoperative ileus or length of hospital stay.

Conclusions

EOF was safe after abdominal emergency surgery. EOF was associated with more vomiting (treated easily and without patient discomfort) and less hunger than with TPC. No other EOF-related benefits could be demonstrated during this trial.     

Adding Gabapentin to a multimodal regimen does not reduce acute pain, opioid consumption or chronic pain after total hip arthroplasty

Background: Gabapentin (GPN) is effective in reducing post‐operative pain and opioid consumption, but its effects with regional anesthesia for total hip arthroplasty (THA) are not known. We designed this study to determine whether (1) gabapentin administration reduces pain and opioid use after THA using a multimodal analgesic regimen including spinal anesthesia; (2) pre‐operative administration of gabapentin is more effective than post‐operative administration. Methods: After REB approval and informed consent, 126 patients were enrolled in a double‐blinded, randomized‐controlled study. Patients received acetaminophen 1 g per os (p.o.), celecoxib 400 mg p.o. and dexamethasone 8 mg intravenously, 1–2 h pre‐operatively. Patients were randomly assigned to one of three treatment groups (G1: Placebo/Placebo; G2: GPN/Placebo; G3: Placebo/GPN). Patients received gabapentin 600 mg (G2) or placebo (G1 and G3) 2 h before surgery. All patients had spinal anesthesia [15 mg (3cc) of 0.5% hypobaric bupivacaine with 10 μg of fentanyl]. In the post‐anesthetic care unit, patients received gabapentin 600 mg (G3) or placebo (G1 and G2). On the ward, patients received acetaminophen 1000 mg p.o. q6h, celecoxib 200 mg p.o. q12h and a morphine PCA device. Patients were interviewed 6 months post‐surgery to determine the incidence and severity of chronic post‐surgical pain. Results: Mean±SD cumulative morphine (mg) consumption (G1=49.4±24.8, G2=47.2±30.1 and G3=56.1±38.2) at 48 h and pain scores at 12, 24, 36 and 48 h post‐surgery were not significantly different among the groups [G1 (n=38), G2 (n=38) and G3 (n=38)]. Side effect profiles were similar across groups. Six months after surgery, the number of patients who reported chronic post‐surgical pain (G1=10, G2=12 and G3=9) and the severity of the pain (G1=4.2±2.9, G2=4.1±2.2 and G3=4.9±2.2) did not differ significantly among the groups (P>0.05). Conclusions: A single 600 mg dose of gabapentin given pre‐operatively or post‐operatively does not reduce morphine consumption or pain scores in hospital or at 6 months after hip arthroplasty within the context of spinal anesthesia and a robust multimodal analgesia regimen.     

Comparison of Two Methods: Spinal Anesthesia and Ischiorectal Block on Post Hemorrhoidectomy Pain and Hospital Stay: A Randomized Control Trial

ABSTRACT

Objective: Hemorrhoidectomy is one of the most common hemorrhoid surgery. Many areas are innervated by nerves, and this makes the surgery to be very painful. Various anesthetic methods have been proposed, and the number of investigations and procedures demonstrated the absence of a reliable method for reducing pain. This study compares the cavity ischiorectal block with spinal anesthesia in reducing postoperative pain, analgesic consumption, and hospital stay. Research design: This study is a randomized control trial carried out on seventy patients sampled. Thirty-five (35) among them were placed in spinal anesthesia group, and the other 35 were placed in the ischiorectal block group. According to the study, questionnaire was designed in such a way that postoperative variables such as postoperative pain, analgesic consumption, changes in blood pressure, heart rate and hospital stay in both groups were evaluated and compared. Clinical trial registration: IRCT2015111616516N3 (http://en.search.irct.ir/search?query=IRCT2015111616516N3) Results: In this study, the pain scores on Visual Analogue Scale (VAS) at 0, 6, 12, and 24 hr for spinal anesthesia group after surgery were 0, 3.08 ± 0.78, 2.05 ± 1.02, 1.11 ± 0.83, respectively (p < 0.05). That of ischiorectal blocks were 0.98 ± 0.25, 1.57 ± 0.81, 0.91 ± 0.91, and 0.63 ± 0.31 respectively, which indicated lesser pain after surgery in the ischiorectal block at 6, 12, and 24 hr. In this study, out of the 35 patients that underwent spinal anesthesia, 28 patients (80%) were hospitalized in the first 6 hr, 13 patients (37.1%) in the second 6 hr, 3 patients (8.6%) in the second 12 hr after surgery. For patients under the ischiorectal block, the number of patients hospitalized were 13 patients (37.1%), in the first 6 hr, 4 patients (11.4%) in the second 6 hr, and 1 (2.9%) were hospitalized in the second 12 hr after surgery (p < 0.05). Conclusion: Ischiorectal blocks causes less pain, require fewer painkillers, and reduces the hospital stay after surgery than spinal anesthesia.     

Usefulness of epidural anesthesia in gynecologic laparoscopic surgery for infertility in comparison to general anesthesia

Background Although the advantages of epidural anesthesia in open surgery have been established, its usefulness in the setting of laparoscopic surgery remains to be studied.Methods Patients undergoing laparoscopic surgery for infertility were randomly administered epidural anesthesia (group A, n = 11) or general anesthesia (group B, n = 9). The operation was performed under 4 mmHg pneumoperitoneum and in the 20° Trendelenburg position. Respiratory function tests using a spirometer and blood gas analysis were performed during the intra- or perioperative period. Pain status was evaluated with visual analog scale scoring. The number of postoperative recovery days needed to resume daily activities was obtained by a questionnaire.Results Respiratory rate, minute volume, P_aCO₂, % vital capacity (VC), and forced expiratory volume in 1 s (FEV1) % were virtually constant throughout the study period in group A, whereas %VC was decreased immediately after operation in group B (p < 0.05). Minute volume immediately after operation was significantly increased in group B compared with group A (p < 0.01), suggesting shallow respiration in women undergoing general anesthesia. Observed pain scores on abdominal pain, shoulder pain, and dyspnea were very low during operation in group A. Pain scores immediately and 3 h after operation were also minimal in group A, whereas abdominal pain scores at these points were significantly higher in group B than those in group A (both p < 0.01). The number of days required for a half reduction in wound pain, trotting, and full recuperation for group A were less than those for group B (p < 0.05).Conclusions Epidural anesthesia, when used in laparoscppic surgery for infertility treatment, has advantages over general anesthesia in terms of analgesic effects, postoperative respiratory function, and a return to preoperative daily activities.     

Acupoint Massage Can Effectively Promote the Recovery of Gastrointestinal Function after Gynecologic Laparoscopy

Abstract

Objective: To investigate the effect of acupoint massage on the recovery of gastrointestinal function in patients after laparoscopic surgery for gynecologic indications. Methods: A total of 160 patients, who underwent gynecologic laparoscopy from December 2015 to January 2017, were recruited. Half of the patients received standard postoperative nursing (i.e., the control group); while the other half received acupoint massage in addition to the standard care (i.e., the observation group). The recovery time of bowel sounds, the first anal exhaust time and the first defecation time were recorded. The plasma levels of motilin, somatostatin and cholecystokinin before and after the surgery were also determined. Results: Compared to the control group, the observation group demonstrated significantly shorter bowel sound recovery time, first anal exhaust time and first defecation time (t?=?11.755, 10.400, 11.950, P?<?0.01 for all comparisons). Before surgery, the plasma levels of gastrointestinal hormones in both groups were comparable. At 12, 24, and 48?hours postoperative, the difference between two groups was statistically significant (P?<?0.05). The overall response rate of the observation group was also significantly higher than that of the control group (control group, 78.75%; observation group, 97.50%; P?=?0.008). Conclusion: Acupoint massage could accelerate the recovery of bowel function after gynecologic laparoscopy by modulating the release of gastrointestinal hormones     

The clinical use of small-dose tetracaine spinal anesthesia for transurethral prostatectomy

In a double-blinded study, we compared conventional dose tetracaine (8 mg), small-dose tetracaine (4 mg) with added fentanyl and epinephrine, and small-dose tetracaine (4 mg) with added fentanyl subarachnoid anesthesia. Forty-five patients scheduled for transurethral resection of prostate (TURP) under subarachnoid anesthesia were randomly assigned to Group 1 (8 mg hyperbaric tetracaine), Group 2 (4 mg hyperbaric tetracaine, 10 microg fen-tanyl, and 0.2 mg epinephrine), and Group 3 (4 mg hyperbaric tetracaine, 10 microg fentanyl, and 0.2 mL saline). Evaluations were performed after spinal anesthesia. Subarachnoid block was successful in all patients except one in Group 1, who required general anesthesia by mask. The median peak sensory levels 10 min after the induction of spinal anesthesia in Group 1 was T8, which was significantly higher than Group 2 and Group 3 (P < 0.05). The time of sensory and motor recovery in Group 3 was less than in Groups 1 and 2 (P < 0.05). Hypotension was observed in four patients in Group 1 and none in Groups 2 and 3. We conclude that small-dose 4-mg hyperbaric tetracaine plus 10 microg fentanyl might provide adequate anesthesia and fewer side effects for TURP when compared with the conventional (8 mg) dose. IMPLICATIONS: Small-dose hyperbaric tetracaine (4 mg with 10 microg fentanyl added) may provide adequate anesthesia and fewer side effects for transurethral resection of the prostate.     

Laparoscopy-assisted subtotal gastrectomy under thoracic epidural-general anesthesia leading to the effects on postoperative micturition

Background Recently, the laparoscopic surgical technique has been widely applied to major surgery as it can minimize surgical incision, reduce blood loss, and shorten hospital stay. In this study, we evaluated the effectiveness of the laparoscopic surgery on postoperative micturitional function in comparison to open surgery. Method Sixty patients undergoing subtotal gastrectomy were assigned to either laparoscopic (L group, n = 30) or open surgery (O group, n = 30) groups. The combined thoracic epidural-general anesthesia was performed on all patients, and epidural patient-controlled analgesia (PCA) using ropivacaine and sufentanil was maintained for two days following surgery. After surgery, visual analog pain score (VAS), levels of sensory and motor block, observer’s assessment of alertness/sedation score (OAA/S), time to first flatus, ambulation and oral intake, and micturition function were assessed. Results The L group showed much earlier ambulation, flatus and oral intake than the O group. Although the scores of VAS and OAA/S were not significantly different between the two groups, the micturition problem scores of the L group were lower than that of the O group (P < 0.05). All patients of the L group had no difficulty in self-voiding, whereas four patients in the O group required urinary catheterization on the first postoperative day (POD1). Conclusions Patients who underwent laparoscopic subtotal gastrectomy had a low incidence of micturitional problem and showed early recovery. Therefore, urinary catheterization on POD1 may not be a routine procedure for those who undergo laparoscopic subtotal gastrectomy under combined thoracic epidural-general anesthesia.     

Temperature control and recovery of bowel function after laparoscopic or laparotomic colorectal surgery in patients receiving combined epidural/general anesthesia and postoperative epidural analgesia

We compared the effects of a laparoscopic (n = 23) versus laparotomic (n = 21) technique for major abdominal surgery on temperature control in 44 patients undergoing colorectal surgery during a combined epidural/general anesthesia. A thoracic epidural block up to T4 was induced with 6-10 mL of 0.75% ropivacaine; general anesthesia was induced with thiopental, fentanyl, and atracurium IV and maintained with isoflurane. Core temperature was measured with a bladder probe and recorded every 15 min after the induction. In both groups, core temperature decreased to 35.2 degrees C (range, 34 degrees C-36 degrees C) at the end of surgery. After surgery, normothermia returned after 75 min (60-120 min) in the Laparoscopy group and 60 min (45-180 min) in the Laparotomy group (P = 0.56). No differences in postanesthesia care unit discharge time were reported between the two groups. The degree of pain during coughing was smaller after laparoscopy than laparotomy from the 24th to the 72nd observation times (P < 0.01). Morphine consumption was 22 mg (2-65 mg) in the Laparotomy group and 5 mg (0-45 mg) in the Laparoscopy group (P = 0.02). The time to first flatus was shorter after laparoscopy (24 h [16-72 h]) than laparotomy (72 h [26-96 h]) (P = 0.0005), and the first intake of clear liquid occurred after 48 h (24-72 h) in the Laparoscopy group and after 96 h (90-96 h) in the Laparotomy group (P = 0.0005). Although laparoscopic surgery provides positive effects on the degree of postoperative pain and recovery of bowel function, the reduction in heat loss produced by minimizing bowel exposure with laparoscopic surgery does not compensate for the anesthesia-related effects on temperature control, and active patient warming must also be used with laparoscopic techniques. IMPLICATIONS: This prospective, randomized, controlled study demonstrates that laparoscopic colorectal surgery results in less postoperative pain and earlier recovery of bowel function than conventional laparotomy but does not reduce the risk for perioperative hypothermia. Accordingly, active warming must be provided to patients also during laparoscopic procedures.     

Effects of fentanyl on emergence characteristics from anesthesia in adult cervical spine surgery: a comparison of fentanyl-based and sevoflurane-based anesthesia

Purpose To evaluate the effects of different anesthesia regimens on bucking, awareness, and pain during the emergence from anesthesia, which may affect neck stabilization and neurological assessment immediately after cervical spine surgery.Methods Patients scheduled to undergo cervical spine surgery were assigned randomly into one of three groups: maintenance of anesthesia with fentanyl and propofol TCI (group FP, n = 25); maintenance with fentanyl and supplementation with less than 1% sevoflurane (group Fs, n = 25); and maintenance solely with sevoflurane (group S, n = 25). The severity of bucking, extent of awareness during neurological examination, and perception of pain during the emergence phase were assessed using predetermined scoring scales by a nurse blinded to the method of anesthesia.Results The bucking score and pain score were significantly better in group FP and group Fs than in the group S, whereas there was no significant difference between the data of group FP and group Fs.Conclusion The quality of emergence from anesthesia in patients with cervical spine surgery is improved with fentanyl-based anesthesia, but there is no difference between the use of propofol TCI and less than 1% sevoflurane as a concomitant sedative agent with fentanyl.     

Is there an advantage in using low-dose intrathecal bupivacaine for cesarean section?

Purpose  Spinal anesthesia for cesarean section is associated with a high incidence of maternal hypotension. The aim of this study was to assess the efficacy of low-dose bupivacaine with fentanyl to reduce the incidence of hypotension in spinal anesthesia for cesarean section. Methods  Forty pregnant women undergoing elective cesarean section were randomly allocated to two groups; those receiving 10 mg bupivacaine to group B (n = 20) and those receiving 4 mg bupivacaine plus 25 μg fentanyl to group BF (n = 20); the agents were given intrathecally with patients in the sitting position, with a combined spinal-epidural technique. Results  Sensory block was adequate for surgery in all patients. Hypotension occurred in all patients in group B (100%) and in 15 patients in group BF (75%). The incidence of hypotension, number of ephedrine treatments, and need for ephedrine were significantly greater in group B than group BF. Three patients in group BF required i.v. fentanyl supplementation after delivery. In 1 of these patients, i.v. fentanyl was not adequate, and epidural supplementation of 1% lidocaine was required. Conclusion  The development of hypotension after spinal block in subjects undergoing cesarean section was not prevented despite low-dose (4 mg) bupivacaine plus 25 μg fentanyl, but the severity of maternal hypotension, and the number of ephedrine treatments and the total dose of ephedrine were decreased.     

First aid and treatment for cervical spinal cord injury with fracture and dislocation

Background:

Traumatic cervical spinal cord injury with subaxial fracture and dislocation not only indicates a highly unstable spine but can also induce life-threatening complications. This makes first aid critically important before any definitive operative procedure is undertaken. The present study analyzes the various first aid measures and operative procedures for such injury.

Materials and Methods:

Two hundred and ninety-five patients suffered from cervical spinal cord injury with fracture and dislocation. The average period between injury and admission was 4.5 days (range 5 h-12 weeks). The injury includes burst fractures (n = 90), compression fractures with herniated discs (n = 50), fractures and dislocation (n = 88) and pure dislocation (n = 36). Other injuries including developmental spinal canal stenosis and/or multi-segment spinal cord compression associated with trauma (n = 12), lamina fractures compressing the spinal cord (n = 6), ligament injuries (n = 7) and hematoma (n = 6) were observed in the present study. The injury level was C4 (n = 17), C5 (n = 29), C6 (n = 39), C7 (n = 35), C4-5 (n = 38), C5-6 (n = 58), C6-7 (n = 49), C4-6 (n = 16) and C5-7 (n = 14). According to the Frankel grading system, grade A was observed in 20 cases, grade B in 91, grade C in 124 and grade D in 60. One hundred and eighteen (40%) patients had a high fever and difficulty in breathing on presentation. First aid measures included early reduction and immobilization of the injured cervical spine, controlling the temperature, breathing support, and administration of high-dose methylprednisolone within eight hours of the injury (n = 12) and administration of dehydration and neurotrophy medicine. Oxygen support was given and tracheotomy was performed for patients with serious difficulty in breathing. Measures were taken to prevent bedsores and infections of the respiratory and urological systems. Two hundred and thirty six patients were treated with anterior decompression, 31 patients were treated by posterior approach surgery and combined anterior and posterior approach surgery was performed in a single sitting on 28 patients.

Results:

All patients were followed for 0.5-18 years (mean 11.8 years). At least one Frankel grade improvement was observed in 178 (60.3%) patients. In the anterior surgery group, the best results were observed in the cases with slight compressive fracture with disc herniation (44/50 patients, 88.0%). In the posterior surgery group, one Frankel grade improvement was observed in the cases with developmental spinal canal stenosis with trauma, lamina fractures, ligament injuries and hematoma (27/31, 87.1%). Most of the patients in the Frankel D group recovered normal neurological function after surgery. The majority of the patients with Frankel C neurological deficit (102/124) had the ability to walk postoperatively, while most of the seriously injured patients (Frankel A and B) had no improvement in their neurological function. Radiolographic fusion of the operated segments occurred in most patients within three months. Loss of intervertebral height and cervical physiological curvature was observed to varying degrees in 30.1% (71/236) of the cases in the anterior surgery group.

Conclusion:

First aid measures of early closed reduction or realignment and immobilization of the cervical spine, breathing support and high-dose methylprednisolone were most important in the treatment for traumatic spinal cord injury. Surgery should be performed as soon as the indications of spinal injury appear. The choice of the approach—anterior, posterior or both, should be based on the type of the injury and the surgeon''s experience. Any complications should be actively prevented and treated.