Ketorolac or fentanyl to supplement local anesthesia?

Study Objective: To evaluate the usefulness of ketorolac in the treatment of intraoperative pain refractory to the administration of local anesthetic alone.

Design: Intraoperative acute-pain treatment model consisting of awake, nonsedated patients who randomly received either an opioid or a study drug in a double-blind fashion.

Setting: University medical center.

Patients: Eighty patients who underwent breast biopsy, lumpectomy, or central venous catheter placement.

Interventions: Patients received either ketorolac 1 mg/kg intravenously (IV) up to a total dose of 60 mg or fentanyl 3 μg/kg IV up to a total dose of 250 μg to supplement the local anesthetic.

Measurements and Main Results: Verbal pain evaluation and the visual analog scale (VAS) were used for perioperative measurement of pain. Heart rate (HR), blood pressure, and respiratory rate (RR) were recorded before and after analgesic drug injections at 10-minute intervals, both intraoperatively and while the patient was in the postanesthesia care unit (PACU). Speed of recovery was quantified by p-deletion and digit substitution tests on admission to the PACU and at 30-minute intervals until discharge. The frequency of nausea, vomiting, and pruritus were recorded. There were no differences between the groups in perioperative verbal pain evaluation, VAS scores, HR, systolic blood pressure, diastolic blood pressure, or RR. Patients who received ketorolac exhibited a significantly lower frequency of intraoperative and postoperative medication administration intraoperatively, than those who received fentanyl. No additional pain medication was required by patients in the PACU in either group.

Conclusions: Ketorolac is a useful alternative to fentanyl for the treatment of intraoperative pain refractory to the administration of local anesthetic alone during monitored anesthesia care. A decided advantage of ketorolac over fentanyl is the absence of nausea and vomiting in the intraoperative and postoperative periods.     

Regional versus general anesthesia in high-risk surgical patients: the need for a clinical trial

Regional anesthesia is often preferred over general anesthesia for patients with cardiovascular disease because of presumed decreased risk of perioperative myocardial ischemia. However, few studies have addressed this issue directly. To determine whether the type of anesthesia is independently associated with myocardial ischemia, records of 134 patients undergoing peripheral vascular grafting under general or regional anesthesia were examined. There were no significant differences preoperatively between groups in ASA class, age, sex, or prevalence of angina, diabetes, or hypertension. Twelve patients developed myocardial ischemia or infarction within 7 days of operation; 11 of these 12 patients had received regional anesthesia (p < 0.015). The association between anesthetic approach and perioperative myocardial ischemia or infarction remained after adjustment for preoperative factors associated with ischemia or with type of anesthesia. General anesthesia does not appear to be associated with increased risk of myocardial ischemia, and stringent recommendations to avoid it in this population may be unfounded. A clinical trial is needed to define more clearly the risks and benefits of different types of anesthesia in high-risk patients.     

The history of trephination in Africa with a discussion of its current status and continuing practice

Trephination of the skull is one of the most fascinating and, certainly, one of the oldest therapeutic procedures known to man. After Prunières' discovery of the trephined skull at Aiguières in 1868, a plethora of information has been gathered about the procedure. There, however, exits little documentation of African trephination or its history. Using both primary and secondary sources, we have discovered that African trephination was known in the time of Herodotus, has a rich history, and is currently practiced widely throughout Africa for specific reasons. We discuss these findings as they relate to preconceived notions of trephinations in other countries and to the history of neurosurgery.     

A hemothorax after thoracic epidural anesthesia

A case of a hemothorax that occurred after thoracic epidural anesthesia is described. This situation might have been caused by accidental puncture of the intercostal vessel and visceral pleura by a Tuohy needle. The risk of causing a pneumothorax and/or hemothorax must be kept in mind when attempting thoracic epidural anesthesia.     

Surgery of incidental intracranial aneurysms

A series of nine patients with an unruptured asymptomatic aneurysm not associated with a ruptured aneurysm is discussed. Three had giant aneurysms. Two patients had bilateral aneurysms of the middle cerebral artery. Five had solitary aneurysms of the middle cerebral artery. One had an aneurysm of the anterior communicating artery. One had an ophthalmic aneurysm. All aneurysms were clipped. Two operations were necessary in the two patients with bilateral aneurysms. There was no mortality and no significant morbidity. Clipping of the aneurysm is recommended for those patients who have no other serious illness that significantly increases the surgical risk. If a combination of pituitary tumor and aneurysm is found, a subfrontal instead of transsphenoidal approach should be considered so as to treat both the tumor and aneurysm at the same operation.     

To define a specialty: A brief history of the American Board of Anesthesiology's first written examination

The initial written examination of the American Board of Anesthesiology, a division of the American Board of Surgery, was given on March 28, 1939. For all anesthesiologists, this date has double significance. First, what was meant by anesthesiology as a medical specialty was defined through the questions posed on the first examination. Second, the physicians being tested that day were among the first physician-anesthetists to exploit the newly created path to recognition as specialists in the science and art of anesthesia by the American medical hierarchy. Gaining the support of organized medicine was an involved and arduous struggle that consumed most of the 1930s. A triumvirate of visionaries, Paul Wood, John Lundy, and Ralph Waters, was necessary to crystalize the goal of specialty recognition of physician-anesthetists. The first written examination was the consummation of this dream of equal status for anesthesia. The examination would not become repetitious, and within the first decade of testing, the style would change from an essay format to multiple-choice questions similar to the current form.     

Diversification in the concept of “birth and death”: The controversy about “brain death and organ transplantation” in Japan

There is a lot of hesitation in Japan in defining brain death as the death of the individual and in proceeding to organ transplantation. Regarding the diagnostic criteria of brain death, those issued by the Japanese Ministry of Health and Welfare in 1985 are sufficient for judgment of brain death. Many people, however, do not accept brain death as death of the individual, and even those who admit brain death as death of the individual hesitate to approve of the actual removal of organs from brain dead patients. Thus, the controversy about brain death in Japan appears to be separated from the objective of organ transplantation.     

Use of cyanoacrylate glue to prepare cultured keratinocyte sheets for grafting

We describe a method to prepare keratinocyte cultured sheets for grafting based on the use of an organic glue (n-butyl-2-cyanoacrylate). It is a rapid and easy method in which the cultured layers of keratinocytes remain with a surface area similar to the original cultures.     

Post-traumatic stress, pain and anxiety in adult burn victims

This article describes the relationship between post-traumatic morbidity, anxious anticipation of pain and pain perception in 33 adult burn patients. Burn patients were assessed, on average, 7 days after admission to the hospital. Five time a day nurses asked the patients to provide pain ratings.

The more patients suffered from post-traumatic stress, the more their anxiety state was elevated. The association between posttraumatic stress and pain perception was, controlling for the effects of anxious anticipation, spurious.     

Patient-controlled drug administration during local anesthesia: A comparison of midazolam, propofol, and alfentanil

Study Objective: To evaluate the perioperative effects of alfentanil, midazolam, and propofol when administered using a patient-controlled analgesia (PCA) device during local anesthesia.

Design: Randomized, single-blind comparative study.

Setting: Outpatient surgery center at a university teaching hospital.

Patients: Ninety outpatients undergoing minor elective surgical procedures with local anesthetic infiltration were assigned to one of three treatment groups.

Interventions: After premedication with midazolam 1 mg intravenously (IV) and fentanyl 50 μg IV, patients were allowed to self-administer 2 ml bolus doses of either alfentanil 250 μg/ml, midazolam 0.4 mg/ml, or propofol 10 mg/ml at minimal intervals of 3 minutes to supplement a basal infusion rate of 5 ml/hr.

Measurements and Main Results: The total intraoperative dosages of alfentanil, midazolam, and propofol were 2.7 ± 1.1 mg, 4.7 ± 2.7 mg, and 114 ± 42 mg, respectively, for procedures lasting 48 ± 28 minutes to 51 ± 19 minutes (means ± SD). Propofol produced more pain on injection (39% vs. 4% and 6% in the alfentanil and midazolam groups, respectively). Episodes of arterial oxygen saturation less than 90% were more frequent with alfentanil (28%) than with midazolam (3%) or propofol (13%). Using the visual analog scale, patients reported comparable levels of discomfort, anxiety, and sedation during the operation in all three treatment groups. Postoperative picture recall was significantly decreased with midazolam versus alfentanil and propofol. Finally, postoperative nausea was reported more frequently in the alfentanil group (29%) than in the midazolam (10%) or propofol (18%) groups, contributing to a significant prolongation of the discharge time in the alfentanil-treated patients.

Conclusions: When self-administered as adjuvants during local anesthesia using a PCA delivery system, alfentanil, midazolam, and propofol were equally acceptable to patients. However, propofol and midazolam were associated with fewer perioperative complications than was alfentanil.     

Arteriovenous malformation associated with moyamoya disease: Case report

A rare case of arteriovenous malformation associated with moyamoya disease is reported. In this case, an interesting angiographic change was obtained during the follow-up period. The feeding artery from the internal carotid artery gradually disappeared as the moyamoya disease progressed, and a new feeding artery appeared from the external carotid artery.     

Challenges in recertification

We must now face perhaps one of the great changes that is emerging in our practice of medicine of this century: recertification, based not on testing of cognitive skills, but focused on a quality assurance program for clinical performance and satisfactory outcome criteria. Certification is not the same as recertification; each serves a necessary function. For recertification we need to be able to assess physician performance in practice. Standard testing practices in graduate medical education work well in the setting for which they were developed. However, we now need to devise better ways to measure the continuing accrual of knowledge and the consequences of the application of that knowledge in the practice of modern medicine. How can such a determination be made? Who will administer the programs? How can we as physicians assure the public that we are capable of maintaining high standards of performance throughout a physician's practice career?     

Boiling wax burn in mid-autumn festival in Hong Kong

An unusual cause of burn, contact with boiling wax by children and adolescents during the annual mid-autumn festival in Hong Kong is presented. 57 patients who suffered from hot wax burn over the period 1986–1996 were admitted to the Burns Unit of the Prince of Wales Hospital. This special burn should be preventable by public education.     

Alignment and technique in total ankle arthroplasty

Total ankle arthroplasty has emerged as a promising alternative to ankle arthrodesis, especially in cases where multiple hindfoot joints are arthritic. Proper alignment of the limb must be restored to be most successful over the long term. Misalignment above the ankle typically involves a malunion of a previous tibia fracture and can be treated by corrective osteotomy. Deformity in the joint itself can arise from congenital malformation or from bony erosion, usually as a late result of joint trauma. Mild amounts of bone loss can be corrected through bone cuts during ankle replacement, but more severe deformity may require distal tibial osteotomy. Misalignment below the ankle (in the foot) is probably the most common deformity. Secondary procedures in the foot and leg, including muscle balancing, osteotomies, or fusions are often a part of the surgical plan and are performed either before or simultaneously with ankle replacement. The goal is to restore an ankle with neutral static and dynamic balance during stance and gait. Achieving that goal will give the best chance for pain free ankle motion over the long term.     

Brain tumors in pediatric patients at king faisal specialist hospital and research centre

We report our experience with brain tumors in pediatric patients, patients who came to our attention when they were aged 14 years or less. In general, the pattern of brain tumors at this Institution is similar to that reported in the neurosurgical literature. Fortunately we have modern diagnostic technology and modern operating instrumentation available to us for dealing with such lesions, which are often in their late stages.     

A role for lasers in the treatment of pigmented skin grafts

The development of aberrant pigmentation represents an unwelcome complication to an otherwise successful split skin graft resulting in a loss of colour match and, so it follows, of cosmesis. We present two cases where lasers have been successful in the treatment of this problem.