Topical vasoconstrictor use for nasal intubation during pregnancy complicated by cardiomyopathy and preeclampsia

Ankylosing spondylitis presents challenges for the obstetric anesthesiologist in administering neuraxial anesthesia or managing the airway. A pregnant patient with ankylosing spondylitis, cardiomyopathy and preeclampsia requiring cesarean delivery was managed with an awake nasotracheal fiberoptic intubation. The use of topical cocaine, epinephrine, phenylephrine, and oxymetazoline to produce nasal vasoconstriction is discussed. Selective alpha-2 agonists that can potentially provide nasal mucosa vasoconstriction and placental vasculature vasodilation are also discussed.     

Cardiovascular responses and lidocaine absorption in fiberoptic-assisted awake intubation

Local anesthetic toxicity and cardiovascular stress during fiberoptic-assisted awake tracheal intubation were assessed prospectively in 20 patients with airway management problems. Cardiovascular responses, dose of lidocaine, its systemic absorption, and patient comfort were measured. A standardized topical anesthesia protocol of 4% lidocaine aerosol, topical 2% lidocaine viscous gel, and direct perbronchoscopic laryngeal application was used. Awake intubation produced no significant elevation of blood pressure or pulse rate either during the topical application or after the intubation. Despite a large total dose of topical lidocaine (5.3 +/- 2.1 mg/kg), the mean peak arterial plasma lidocaine concentration was low (0.6 +/- 2.1 micrograms/ml). Patient comfort assessment showed that nine patients had no discomfort, whereas 11 had minimal discomfort. Supplementary sedation used was minimal (fentanyl, 1.4 +/- 0.6 micrograms/kg, and diazepam, 1.9 +/- 1.8 mg). This method of producing topical anesthesia for awake tracheal intubation is recommended as a safe, easy, and comfortable method of managing patients with airway difficulties.     

Prolonged perioperative myocardial ischemia in a young male: due to topical intranasal cocaine?

We present a case of prolonged myocardial ischemia in a young healthy male presenting for nasal polypectomy and tonsillectomy. Induction of anesthesia proceeded uneventfully. Immediately after surgical incision, the patient developed a sinus tachycardia with ST-segment depression in leads II and III, and ST elevation in leads aVR, aVL, aVF, and V. Depth of anesthesia was increased, esmolol was administered, which slowed the heart rate, and the procedure was terminated. However, myocardial ischemia only gradually resolved, leaving residual T-wave flattening in lead III by day 3 postoperatively. After extensive investigation to rule out other causes of ischemia, we considered cardiotoxicity due to intranasally administered cocaine with epinephrine to be the most likely precipitant. Nasal packing with gauze soaked in a solution containing cocaine 3 mg/kg and epinephrine 1 mg occurred just 40 minutes prior to induction of anesthesia. Topical intranasal cocaine is rapidly and reliably absorbed systemically, with peak plasma concentrations occurring within 30 to 60 minutes, corresponding to the time course of cocaine administration and surgical stimulation in this patient. Systemic absorption of topical intranasal cocaine has previously been reported to cause adverse cardiac sequelae, including myocardial infarction. This report reinforces the need for caution regarding the use of topical intranasal cocaine, particularly if used in combination with epinephrine.     

Rapid oral anesthesia for awake intubation.

STUDY OBJECTIVE: To determine whether sodium benzonatate (Tessalon Perles) can provide rapid, effective topical oral anesthesia in preparation for awake intubations. DESIGN: Randomized, controlled, single-blind study. SETTING: Medical center anesthesia department. PATIENTS: Forty patients counseled for an awake intubation. INTERVENTIONS: The patients were randomized (random permutated block) to receive either benzonatate 200 mg topically for oropharyngeal anesthesia or bilateral superior laryngeal nerve blocks (total 8 ml of 1% lidocaine) in conjunction with 2 ml of 20% benzocaine orally. Both groups were administered 4 ml of 4% lidocaine translaryngeally. If nasal intubation was anticipated, the patients received 6 ml of 2% lidocaine jelly for nasal anesthesia. MEASUREMENTS AND MAIN RESULTS: The time to obtain oropharyngeal anesthesia was measured as the time from obtaining the benzonatate capsules from the bottle or palpation of the neck to locate the hyoid bone to the time when the patient exhibited an absent gag response to an oropharyngeal airway. After completion of airway preparation, the patient's response to intubation was evaluated by an anesthesiologist blinded to the method of preparation. Medications administered for sedation and analgesia were recorded. Noninvasive blood pressure, heart rate (HR), cardiac rhythm, and three-lead ST segments (I, II, V5) were recorded and evaluated for changes from baseline. Postoperatively, the patient was questioned for recall of the intubation. The time required to obtain loss of the gag response was shorter in the benzonatate group (55.1 +/- 5.7 seconds vs 339 +/- 22.4 seconds, p less than 0.005). The patient response to intubation was similar in both groups (90% no response, 10% minimal response). No abnormal cardiac rhythms or ST segment depression occurred, and mean arterial pressure and HR did not increase more than 20%. CONCLUSIONS: The results of this study indicate that benzonatate capsules provide rapid and reliable oropharyngeal anesthesia in preparation for awake intubation. In addition, if excellent airway anesthesia is provided, awake intubations can be accomplished with minimal patient response and discomfort.     

Effect of intraprostatic local anesthesia during transrectal ultrasound guided prostate biopsy: comparison of 3 methods in a randomized, double-blind, placebo controlled trial

PURPOSE: We evaluated the effect of intracapsular anesthesia and periprostatic nerve block during transrectal ultrasound guided prostate biopsy. MATERIALS AND METHODS: In a prospective, randomized, double-blind, placebo controlled study 152 consecutive patients were randomized into 3 groups. Group 1 of 41 patients was administered intraprostatic local anesthesia into the right and left sides with a total of 2 ml 1% lidocaine and a periprostatic injection of 2 ml saline later. Group 2 of 49 patients was administered intraprostatic injection of 2 ml saline, followed by periprostatic local anesthesia with 2 ml 1% lidocaine. Group 3 of 62 patients received intraprostatic and periprostatic local anesthesia with 2 ml 1% lidocaine. Patients were asked to grade the pain level using a 10-point linear visual analog pain scale 1) when the transrectal ultrasound probe was inserted, 2) during anesthesia, 3) during biopsy and 4) 20 minutes after biopsy. One-way ANOVA and the Kruskal-Wallis test with the Tukey post hoc test were used to compare patient characteristics and pain scale responses among the 3 groups. RESULTS: No major complications, including sepsis and severe rectal bleeding, were noted in any patient. There were statistically significant differences in pain scores among groups 1 to 3 during anesthesia (mean +/- SD 5.6 +/- 2.5, 6.7 +/- 2.3 and 4.9 +/- 2.1, p = 0.003) and during biopsy (4.3 +/- 2.7, 4.5 +/- 2.6 and 2.7 +/- 2.1, respectively, p = 0.032). There were no differences in pain scores among the 3 groups during probe insertion (p = 0.39). CONCLUSIONS: A combination of intracapsular anesthesia and periprostatic nerve block is an effective and useful technique that is well tolerated by the patient. It decreases the level of pain and discomfort associated with the prostatic biopsy procedure.     

Cocaine and lidocaine as topical urethral anesthetics

To evaluate the efficacy of topical cocaine combined with lidocaine as a urethral anesthetic, a double-blind, randomized, prospective study was performed comparing lidocaine combined with cocaine or placebo in male outpatient cystoscopy. Evaluations were based on a scale of 1 to 10, with 1 representing no discomfort and 10 extreme discomfort as judged by the patient, and 1 representing the best tolerance and 10 extreme intolerance as judged by the physician. Patients who received lidocaine plus cocaine reported a mean score of 3.33 for over-all discomfort of cystoscopy. This was not significantly different than for lidocaine alone. This finding indicates a lack of a summation effect in combining topical anesthetics. Patients undergoing repeat examinations were no more comfortable than those undergoing initial cystoscopy but older patients tolerated the procedure significantly better than younger patients.     

Controlling bleeding from superficial wounds by the use of topical alpha adrenoreceptor agonists spray. A randomized, masked, controlled study

In an attempt to determine whether alpha adrenergic agonists sprayed directly over the wound are able to reduce a superficial bleeding, phenylephrine (0.25%), oxymetazoline (0.05 and 0.25%) and saline (0.9%) were tested in a rat model. The study was randomized, controlled and quantitative. A total of four incisions were made in each rat, and each solution was sprayed directly on the incision according to a specific protocol. The bleeding times were measured and summed up. Biases were minimized by the fact that each rat received all four solutions, including the control, in all possible combinations. The mean bleeding time after spraying phenylephrine (0.25%) was significantly shorter than the mean bleeding time after spraying saline (1.90 +/- 0.14 min versus 4.80 +/- 0.43 min, respectively, P < 0.001) and significantly shorter than the mean bleeding time after spraying oxymetazoline (0.05 or 0.25%: 4.46 +/- 0.54 and 5.50 +/- 0.58 min, respectively, P < 0.001). No statistically significant difference was found between the mean bleeding time after spraying oxymetazoline (0.05 or 0.25%) compared with saline. We conclude that sprayed phenylephrine (0.25%) can be used for reducing superficial bleedings. This method is simple, cost-effective, does not cause further trauma to the tissue, and can be used to treat several bleedings simultaneously (especially abrasions and lacerations) with a single application, without the need for direct physical contact with the bleeding sites. The method is apparently safe, but further studies are needed to test the systemic effect of the sprayed solution.     

Combined spinal-epidural anesthesia using epidural volume extension leads to faster motor recovery after elective cesarean delivery: a prospective, randomized, double-blind study

Epidural volume extension (EVE) via a combined spinal-epidural (CSE) technique is the enhancement of a small-dose intrathecal block by epidural saline boluses. In this prospective, randomized, double-blind study, we compared the EVE technique with single-shot spinal anesthesia with respect to its sensory and motor block profile and hemodynamic stability. Sixty-two parturients (n = 31 in each group) undergoing elective cesarean deliveries were administered either spinal anesthesia with hyperbaric 0.5% bupivacaine 9 mg and fentanyl 10 microg or CSE comprising intrathecal hyperbaric 0.5% bupivacaine 5 mg with fentanyl 10 microg, followed by 0.9% saline 6.0 mL through the epidural catheter 5 min thereafter. In each group, the lowest systolic blood pressure (SBP), sensory block level to loss of pain from pinprick, and modified Bromage scores were recorded at 2.5-min intervals. The visual analog pain score (VAS), peak sensory block height, highest modified Bromage motor score, time for sensory regression to the tenth thoracic dermatome (T10), and motor block recovery were compared between groups. Both groups were comparable in demographic data, VAS scores, peak sensory block height, time for sensory regression to T10, and lowest SBP recorded. Patients in the EVE group demonstrated significantly faster motor recovery to modified Bromage 0 (73 +/- 33 min versus 136 +/- 32 min, P < 0.05). IMPLICATIONS: When compared with conventional, single-shot spinal anesthesia, epidural volume extension of a small-dose spinal block provides satisfactory anesthesia for cesarean delivery with only 55% of the bupivacaine dose required and is associated with faster motor recovery of the lower limbs.     

静注曲马多预防小儿全麻苏醒期躁动的临床观察

目的 观察曲马多预防小儿全麻苏腥期躁动的效果.方法 选择全麻下行扁桃体和(或)腺样体摘除术的患儿40例,年龄3～8岁,随机均分为曲马多组和对照组,全麻插管后分别静注曲马多2mg/kg或相同容量的生理盐水.记录手术时间、麻醉时间、拔管时间并测定拔管前两组患儿的Comfort评分及苏醒期间的躁动评分,观察有无恶心呕吐、术后低氧血症、反流误吸等不良反应.结果 两组患儿的手术时间、麻醉时间、拔管时间、术后低氧血症、恶心呕吐发生率差异均无统计学意义.Comfort评分:镇静满意率曲马多组为80%,明显优于对照组的45%(P<0.05).躁动评分:曲马多组中无或轻度躁动的比率为85%,明显优于对照组的45%(P<0.05).结论 小儿扁桃体和(或)腺样体摘除术前静注曲马多2 mg/kg可获得苏醒期良好的镇静效果,减少拔管期的躁动,且不增加拔管时间、术后低氧血症、恶心呕吐、反流误吸等不良反应发生率.     

The efficacy of tolterodine for prevention of catheter-related bladder discomfort: a prospective, randomized, placebo-controlled, double-blind study

Bladder discomfort secondary to an indwelling urinary catheter is distressing, particularly for patients awakening from anesthesia. We sought to discover the incidence and severity of bladder discomfort in patients who were catheterized intraoperatively and to evaluate the efficacy of tolterodine, a pure muscarinic receptor antagonist, in preventing this. Two-hundred-fifteen consecutive adult patients, ASA physical status I and II, either sex, undergoing urologic surgery requiring bladder catheterization were enrolled. Group C (control, n = 165) received placebo and group T (tolterodine, n = 50) received tolterodine 2 mg. Drugs were administered orally 1 h before surgery. After induction of anesthesia, patients were catheterized with a 16F Foley catheter and the balloon was inflated with 10 mL of normal saline. In the postanesthesia care unit, bladder discomfort was assessed on arrival (0), 1, 2 and 6 h. Severity of bladder discomfort was graded as mild, moderate, and severe. Bladder discomfort observed in group C was 55% (91 of 165). Tolterodine reduced both the incidence 36% (18 of 50) and severity of bladder discomfort (P < 0.05). IMPLICATIONS: Bladder discomfort secondary to an indwelling urinary catheter is distressing to patients. In the present study, we observed that tolterodine (2 mg), a competitive muscarinic receptor antagonist administered 1 h before surgery, reduced both the incidence and severity of bladder discomfort secondary to bladder catheterization.     

Topical anesthesia for cataract surgery with phacoemulsification: lidocaine 2% vs ropivacaine 1%. Preliminary results

BACKGROUND: The safety, tolerability and efficacy of ropivacaine 1% vs lidocaine 2% for phacoemulsification using topical anesthesia during cataract surgery, are compared. METHODS: A prospective, randomized, double-blind study comparing two agents for topical anesthesia is reported. Environment: Operative Unit of Ophthalmology, general Hospital. 1893 consecutively patients were studied (ASA 1-3, 738 males, 1155 females, age 71.8+/-9.7 years, range 35-90 years) undergoing routine phacoemulsification under topical 2% lidocaine (group I) and 1% ropivacaine (group II). The mains outcome measures of the study were: - the total dose of local anesthetic for obtaining a reduction of corneal sensation measured with the Cochet-Bonnet esthesiometer (value>3); - the pain recorded with visual analogic scale and verbal scale at: T1 = the first injection of local anesthetic; T2 = corneal incision; T3 = the end of surgery; T4 = 1h after surgery; T5 = the first postoperative day; - any requirement for additional intraoperative injection anesthesia and systemic sedation when needed; - surgeon assessments of operative conditions and patient cooperation; - patients' subjective level of comfort; - complications. RESULTS: Topical anesthesia using lidocaine 2% was significantly more painful than the ropivacaine 1%. The onset of anesthesia adequate for surgery was similar in all two groups. There were differences between the groups with respect to perioperative analgesia because the VAS was significantly higher in lidocaine group than in ropivacaine group. There were no statistically differences between the two groups at the follow-up. Inadequate anesthesia was seen in 8.05% (74/919 patients) cases of group I vs 0.9% (22/974 patients) of group II. Sedation was needed only in 10 patients and 6 patients of group I and II respectively. The surgeon assessment showed more patient cooperation in the ropivacaine group (83%). Satisfactory comfort (level 1) was reported by 60.4% in the lidocaine group and 86.8% in the ropivacaine group. In both groups there were cases of postoperative epithelial edema (29 patients in group I vs 36 patients in group II) although it decreased after the first postoperative day. No other significant side-effects were observed with the use of either formulations. CONCLUSIONS: Lidocaine 2% and ropivacaine 1% were safe and effective agents in patients having phacoemulsification with IOL implantation. However, ropivacaine provides more good operative conditions than lidocaine for the surgeon and comfortable surgical circumstances for the patient.     

Use of mometasone furoate aqueous nasal spray in the treatment of rhinitis medicamentosa: an experimental study.

OBJECTIVE: We aimed to investigate, histopathologic changes in the nasal mucosa of guinea pig's after prolonged administration of oxymetazoline and the development of rhinitis medicamentosa, and the efficacy of mometasone furoate aqueous nasal spray and saline in reversing the ultrastructural changes attributable to rhinitis medicamentosa. METHODS: In the study, 24 male guinea pigs (500 to 600 gr) were used. Oxymetazolin (0.05%) was sprayed into the nasal cavities of the guinea pigs 3 times daily for 8 weeks. At the end of this period, 6 guinea pigs were killed and examined to make sure that the animals had developed rhinitis medicamentosa. The remaining guinea pigs were randomly divided into 3 groups. In the first group, one spray-puff of 0.05% mometasone furoate aqueous nasal spray (50 microg) was applied twice daily for 14 days. In the second group, saline solution (0.9% NaCl) was applied twice daily for 14 days. No treatment was performed in the third group. At the end of the treatment period, nasal mucosal changes were evaluated by light microscopy and electron microscopy. RESULTS: After oxymetazolin application for 8 weeks, the main histologic changes were edema, congestion, proliferation of subepithelial glands, and squamous cell metaplasia. After topical mometasone furoate aqueous spray application for 2 weeks, the edema fluid was found to diminish markedly. In the saline and no treatment groups, edema and congestion continued. In these groups of guinea pigs, fibrosis has been seen in the nasal mucosa. CONCLUSION: We found that mometasone furoate nasal spray was effective against experimentally induced rhinitis medicamentosa in guinea pigs. Mometasone furoate nasal spray may have value in the treatment of patients with rhinitis medicamentosa.     

Office based transurethral needle ablation of the prostate with analgesia and local anesthesia

PURPOSE: We evaluated the efficacy and feasibility of performing office based transurethral needle ablation of the prostate with analgesia and local anesthesia. MATERIALS AND METHODS: A total of 56 consecutive patients underwent transurethral needle ablation of the prostate for symptomatic benign prostatic hyperplasia. Oral rofecoxib (50 mg) and ciprofloxacin (250 mg) were administered before the procedure with 25 mg hydroxyzine and 50 to 100 mg meperidine intramuscularly. A combination of 2% lidocaine solution and jelly was used for anesthesia. Patients rated discomfort during anesthesia administration and the procedure using a 10-point scale of 0--no discomfort to 10--the worst pain/discomfort ever experienced in the patient life. Overall satisfaction with the procedure was assessed with a 4-point scale of 1--very satisfactory to 4--very unsatisfactory. Followup was 12 months for uroflow and 36 months for International Prostate Symptom Score. RESULTS: The mean age of 47 patients was 65.4 years. Mean discomfort ratings were 3.6 and 4.9 for anesthesia administration and the procedure, respectively. Average operative time was 34.4 minutes, excluding anesthesia administration. The mean overall satisfaction score was 1.5. The mean preoperative International Prostate Symptom Score was 23.1, which improved to 10.9, 11.2, 12.3, 13.8 and 11.3 at 3, 6, 12, 24 and 36 months, respectively. Mean maximum uroflow improved from 8.2 ml/sec at baseline to 12.8, 13.9 and 13.3 ml/sec at 3, 6 and 12 months, respectively. CONCLUSIONS: Administration of an intramuscular narcotic combined with oral analgesic and topical lidocaine provided adequate pain control for transurethral needle ablation of the prostate, making it a feasible office procedure.     

Cocaine uses and abuses

Cocaine is a time-honored topical anesthetic for intranasal surgery. It combines superb anesthesia with constriction of nasal vasculature and patient euphoria, which facilitates surgery and enhances its tolerability to the patient. Dosages of 200 mg (2 ml of 10% solution) are considered safe and effective for surgical anesthesia. Central nervous system excitability is the predominant toxic reaction followed by convulsions and apnea, which require respiratory support. Intravenous diazepam effectively averts this reaction. Cardiovascular toxicity appears at higher dosages (such as with ingestion for concealment during smuggling) or when epinephrine is concurrently used with cocaine. Cocaine is also damaging to nasal membranes and the nasal septal cartilage, due to its vasoconstrictive effect and the irritative effects of its diluting contaminants. Its major psychological effect is stimulation similar to that of the amphetamines. Prolonged recreational use may lead to paranoia and violent, antisocial behavior, including homicide and suicide.     

Pain perception during transrectal ultrasound guided prostate needle biopsy: an objective analysis of local anesthesia use

We assessed the effect of periprostatic nerve blockade during transrectal ultrasound of the prostate prior to obtaining systematic needle biopsies and the discomfort associated with this procedure. A prospective randomized study was performed on 100 men requiring systematic needle biopsy of the prostate. Patients were assigned to two groups: Group 1 received no local anesthesia and Group 2 received a periprostatic injection of 5 ml 1% lidocaine solution (2.5 ml bilaterally) prior to undergoing biopsy of the prostate. The patients were asked to respond to a pre- and post-procedural questionnaire which consisted of four questions designed to evaluate pain perception and pain experienced, respectively, during the entire procedure. Mean pain scores for Group 1 responses vs Group 2 responses were not statistically different for any of the pre-procedural questions. Post-procedural pain scores were significantly lower in Group 2 vs Group 1 (control) for questions 1 and 3: question 1 (2.6+/-1.8 vs 3.8+/-1.8, P<0.05), question 2 (3.0+/-1.9 vs 3.7+/-2.1, P=0.14). Question 3 (2.8+/-2.0 vs 4.3+/-1.9, P<0.05), and question 4 (1.6+/-2.4 vs 2.1+/-2.6, P=0.38). During the study, no patient from Group 2 experienced any adverse reaction from the injection. Our data suggest that periprostatic nerve blockade during transrectal ultrasound of the prostate results in less patient discomfort.     

A comparison of the Enk Fiberoptic Atomizer Set™ with boluses of topical anaesthesia for awake fibreoptic intubation

We compared the Enk Fiberoptic Atomizer Set^? with boluses of topical anaesthesia administered via the working channel during awake fibreoptic tracheal intubation in 96 patients undergoing elective surgery. Patients who received topical anaesthesia via the atomiser, compared with boluses via the fibreoptic scope, reported a better median (IQR [range]) level of comfort: 1 (1–3 [1–10]) vs. 4 (2–6 [1–10]), p < 0.0001; experienced a reduced total number of coughs: 6 (3–10 [0–34]) vs. 11 (6–13 [0–25]), p = 0.0055; and fewer distinct coughing episodes: 7% vs. 27% respectively, p = 0.0133. The atomiser technique was quicker: 5 (3–6 [2–12]) min vs. 6 (5–7 [2–15]) min, p = 0.0009; and required less topical lidocaine: 100 mg (100–100 [80–160]) vs. 200 mg (200–200 [200–200]), p < 0.0001. Four weeks after nasal intubation, the incidence of nasal pain was less in the atomiser group compared with the control group (8% vs. 50%, p = 0.0015). We conclude that the atomiser was superior to bolus application for awake fibreoptic tracheal intubation.     

Reversal of lidocaine with epinephrine epidural anesthesia using epidural saline washout

BACKGROUND AND OBJECTIVES: Prolonged motor and sensory block following epidural anesthesia can be associated with extended postoperative care unit stays and patient dissatisfaction. Previous studies have demonstrated a more rapid motor recovery following the administration of epidural crystalloids in patients who had received plain bupivacaine and lidocaine epidural anesthesia. However, epinephrine is commonly added to local anesthetics to improve the quality and prolong the duration of the epidural block. The objective of this study was to determine the relationship of 0.9% NaCl epidural catheter flush volume (i.e., washout) to the recovery of motor and sensory block in patients undergoing 2% lidocaine with epinephrine epidural anesthesia. METHODS: A prospective, randomized, double-blind study design was utilized. Thirty-three subjects scheduled for elective gynecologic or obstetrical surgical procedures underwent epidural anesthesia using 2% lidocaine with epinephrine (1:200,000). A T4 dermatome level of analgesia, determined by toothpick prick, was maintained intraoperatively. Following surgery, subjects were randomized to 1 of 3 treatment groups. Group 1 (control, n = 11) received no epidural 0.9% NaCl (normal saline [NS]) postoperatively. Group 2 (15 mL NS x 1, n = 10) received an epidural bolus of 15 mL NS. Group 3 (15 mL NS x 2, n = 12) received an epidural bolus of 15 mL NS postoperatively and a second 15-mL NS bolus 15 minutes later. Assessment of motor and sensory block was performed at 15-minute intervals until complete motor and sensory recovery. RESULTS: Times to partial and full motor and sensory recovery were significantly faster in the epidural NS groups than in the control group. Full motor recovery was more rapid in subjects receiving two 15-mL NS epidural NS boluses (30 mL total) compared with those receiving a single 15-mL NS bolus (108 +/- 9 min v 136 +/- 13 min) and significantly faster than control group subjects (153 +/- 14 min). Both NS x 1 and NS x 2 epidural bolus groups experienced significantly reduced times to complete sensory recovery when compared with the control group (NS x 1 = 154 +/- 13 min, NS x 2 = 153 +/- 9 min, control 195 +/- 14 min). CONCLUSIONS: A more rapid recovery of motor and sensory block in patients undergoing 2% lidocaine with epinephrine epidural anesthesia can be achieved with the use of 30 mL NS epidural washout. Reg Anesth Pain Med 2001;26:246-251.     

A study of the effect of nasal steroid sprays in perennial allergic rhinitis patients with rhinitis medicamentosa.

OBJECTIVE: To determine if rebound congestion can be reduced with concomitant nasal steroid spray usage. STUDY DESIGN AND SETTING: Randomized, double blind, controlled single center study. PARTICIPANTS: Twenty subjects with perennial allergic rhinitis with nasal congestion. INTERVENTION: All subjects received 3 weeks of twice-daily oxymetazoline. After 2 weeks, subjects were randomized to 2 additional weeks of concomitant budesonide aqueous nasal spray (n = 9) or placebo (n = 10). In the sixth week, all sprays were stopped. RESULTS: Both groups showed subjective and objective evidence of rebound congestion 24 hours after cessation of oxymetazoline (P < 0.05). Subjective rebound congestion resolved in 48 hours in the budesonide aqueous nasal spray group but persisted for over 1 week in the placebo group. CONCLUSION: Rebound congestion is objectively present in patients with perennial allergic rhinitis after 3 weeks of oxymetazoline spray. Rebound congestion is reduced by concomitant budesonide aqueous nasal spray use. SIGNIFICANCE: This study supports the common clinical practice of nasal steroid sprays to ameliorate rebound congestion concomitant with and after cessation of topical decongestant sprays.     

Efficacy of aprotinin in children undergoing craniofacial surgery

OBJECT: This prospective, randomized, placebo-controlled, double-blind trial was undertaken to assess the efficacy of aprotinin in reducing the need for blood transfusions in 39 children undergoing reconstructive craniofacial surgery. METHODS: Two demographically similar groups--a total of 39 patients with a mean age of 1.2 +/- 1.2 years--were studied. The efficacy of aprotinin (240 mg/m2 administered intravenously over 20 minutes, followed by infusions of 56 mg/m2/hr) was compared with that of an equal infusion of 0.9% saline (placebo). Patients in the aprotinin group received less blood per kilogram of body weight than patients in the placebo group (32 +/- 25 ml/kg compared with 52 +/- 34 m/kg, respectively; p = 0.04). Those patients in whom aprotinin was administered experienced less change in their hematocrit levels during surgery (aprotinin -33 +/- 13% compared with placebo -44 +/- 9%, p = 0.01). Each patient underwent a transfusion as per study protocol, and there was no significant change in hematocrit levels from the beginning to the end of surgery. The surgical faculty judged blood loss in patients in the aprotinin group to be significantly less than usual (p = 0.03). The use of aprotinin was also associated with reduced blood transfusion requirements during the first 3 postoperative days (p = 0.03). There was no adverse event reported in either the aprotinin or placebo group. CONCLUSIONS: Aprotinin decreased blood transfusion requirements in pediatric patients undergoing craniofacial reconstruction, thereby reducing the risks associated with exposure to banked blood components.