Lumbar Disc Surgery in Regional Anaesthesia – 40 years of Experience

Summary  Lumbar disc operations have been performed in Brno since 1952 and from the very beginning they are performed under regional anaesthesia. Since 1965 until 1999 about 16000 operations for herniated discs have been performed here. The number of operations doubled with the foundation of the second neurosurgical department in Brno in 1992. Lumbar disc surgery represents 25% of the operation spectrum in our department.  Epidural anaesthesia is advantageous for less risk of some complications compared with general anaesthesia and enables communication between the surgeon and the patient. Other advantages are: less visible bleeding in the operative field due to the lateral position and the fact that the surgeon can sit during the operation. On a long-term basis we found 4–5% had further surgery for reccurent problems. Objective neurological evaluation 6 weeks after the operation showed improvement in 92% of patients. The patients themselves consider their status as very good or satisfactory in 82% (median 3 years after the operation). Besides a correctly performed operation we emphesize also the role of correct diagnosis (good correlation between the patient's problems and CT scan finding) for a good treatment result.     

Anaesthesia for shoulder surgery

This article discusses the pertinent issues related to anaesthetic management of patients undergoing surgical procedures on the shoulder. The interscalene brachial plexus block remains the regional anaesthetic technique of choice but has a high incidence of ipsilateral phrenic nerve palsy. Alternative diaphragm-sparing approaches (e.g. superior trunk block, suprascapular nerve block) have been described. Other specific intraoperative issues include airway considerations and concerns related to patient positioning.     

Anaesthesia for joint replacement surgery

Joint replacement, especially hip and knee, are increasingly common elective orthopaedic procedures. Patients who undergo these operations are usually elderly and may have multiple comorbidities requiring careful perioperative management. Specific issues include deep venous thromboembolism (DVT) prophylaxis and use of regional anaesthesia, potential blood loss and hypothermia, application of pneumatic tourniquet and use of bone cement, and postoperative mobilization. There is a trend for developing clinical pathways or protocols from preoperative assessment through postoperative pain management to improve outcomes and enhance recovery in these patients.     

Regional anaesthesia for eye surgery

Many ophthalmic procedures are conducted under a range of local anaesthetic techniques. These range from topical drops through to sharp needle blocks with local anaesthetic. The most commonly used block is the sub-Tenon block; it provides excellent operating conditions while reducing complications and risks.     

Ventilation-Perfusion Relationships during Anaesthesia and Abdominal Surgery

Nine patients, 61–72 years old, were studied awake and during halothane anaesthesia before and during upper abdominal surgery. Central circulation was evaluated by means of pulmonary artery catheterization and gas exchange by multiple inert gas elimination technique. Awake and supine, a rather wide distribution of _A/ was observed, with regions of low _A/ in five patients and a small shunt (1–3%) in three patients. The overall dispersion of blood flow was log s.d. 0.93. With anaesthesia and mechanical ventilation, cardiac output fell by 30%, whereas pulmonary vascular pressures remained unaltered. The dispersion of pulmonary blood flow against _A/ ratios was further increased with a log s.d. of 1.67. Perfusion of regions with a low _A/ was significantly increased. With surgery, no significant changes were seen in cardiac output or vascular pressures. True shunt appeared or increased in seven patients, ranging from 1.3 to 17%. Perfusion to regions with low _A/ did not change. It is concluded that abdominal surgery interferes with gas exchange, presumably because of a cranial shift of the diaphragm which lowers FRC and thereby promotes airway closure.     

Influence of Anaesthesia on Blood Flow to the Calves During Surgery

The blood flow to the calves during abdominal surgery under different kinds of general anaesthesia was measured by strain gauge plethysmography in 12 patients. The volume flow increased 100% during surgery in both light and deep anaesthesia, caused by a decrease in peripheral resistance. The increase in volume flow could partly be explained by the anaesthesia itself, possibly induced by the use of a nitrous oxide-oxygen gas mixture. The surgical procedure caused a further increase in volume flow. Possible underlying mechanisms are discussed.     

Anaesthesia for urological surgery

Anaesthesia is commonly used to facilitate urological procedures and many patients are elderly with multiple comorbidities. Urological procedures range from minor day case to major surgery in which extensive resources are needed both intraoperatively and postoperatively. For simple day case procedures like cystoscopy or ureteroscopy, general anaesthesia is most commonly used because it allows for early ambulation. Transurethral resection of the prostate (TURP) needs special attention. TURP syndrome due to excessive absorption of the irrigation fluid can be catastrophic if not managed early. Avoiding contributing factors and choosing regional anaesthesia which allows for early detection are key. Careful perioperative planning and risk stratification is important in major urological cancer surgery. Most of these procedures will require general anaesthesia (due to longer operative time and more extensive surgical trauma). Postoperative pain management in the form of epidural or patient-controlled multimodal analgesia are essential. Postoperative high-dependency care is beneficial.     

Regional anaesthesia and blood loss

Epidural and spinal anaesthesia for various types of surgery offer advantages over general anaesthesia by decreasing blood loss and transfusion requirements. This paper focuses on the importance of the choice of anaesthesia on surgical blood loss in total hip arthroplasty. Haemodynamic differences, with lower arterial blood pressure, lower central venous blood pressure, and most importantly lower peripheral venous blood pressure in the surgical wound seem to explain the lower blood loss intra- and post-operatively in patients given regional anaesthesia. These differences in haemodynamics give rise to less arterial, and notably less venous oozing of blood from the surgical area. The latter observation is strengthened by the significant correlations between the intraoperative peripheral venous blood pressure and the intraoperative blood loss. The reduction in blood loss and consequently the reduced transfusion requirements in regional anaesthesia are beneficial in decreasing the hazards and costs of homologous blood transfusion. Although impossible to quantify, reduced bleeding also greatly facilitates the surgeon's work.     

Advantage of Intravenous Anaesthesia for Acute Stage Surgery of Aneurysmal Subarachnoid Haemorrhage

Summary  To investigate the clinical effects of intravenous anaesthesia on surgical procedure and the outcome in acute stage surgery for aneurysmal subarachnoid haemorrhage (SAH), pre-, intra-, and post-operative factors were analyzed to compare between inhalational (IA, n=38) and intravenous (IVA, n=37) anaesthesia. IVA significantly shortened the duration of surgery (p<0.05) and the duration of hospital stay (p<0.01). These results suggest that IVA may be more suitable than IA for acute stage surgery of aneurysmal SAH. These effects may be mainly caused by IVA's pharmakokinetics, by effects on intracranial homeostasis and metabolism, and neuroprotective properties.     

Regional anaesthesia for ophthalmic surgery

Ophthalmic surgery can be conducted under local anaesthesia (LA), with techniques ranging from topical anaesthetic drops to sharp needle regional blocks. The sub-Tenon's block is the most common regional technique in current practice superseding sharp needle techniques (e.g. retrobulbar block). A sub-Tenon's block is a safe and effective means of providing analgesia, anaesthesia and good operating conditions.     

局麻和硬膜外麻醉下腹股沟疝无张力修补手术的比较分析

目的探讨腹股沟疝无张力修补更适宜的麻醉方式。方法将我院2002年3月至2005年3月收治的单侧腹股沟疝病例422例按随机数字表法分为局麻组和硬膜外麻醉组，手术方法均采用充填式无张力疝修补，设定观察指标，记录相关数据（包括手术时间、下地时间、进食时间、住院时间、恢复日常生活时间、伤口并发症、术后麻醉并发症、辅助药物使用率、麻醉满意率及住院费用），填写问卷调查表并进行随访。结果局麻组和硬膜外麻醉组的辅助药物使用率、伤口并发症发生率、手术时间及恢复日常生活时间比较，差异均无统计学意义（P〉0、05）；在对麻醉满意率方面两组均为总体满意。局麻组下地时间、进食时间、住院时间、术后麻醉并发症（恶心／呕吐、尿潴留）发生率及住院全部费用均明显低于硬膜外麻醉组，两组差异有统计学意义（P〈0．05）。随访期间，两组患者均无复发。结论大多数腹股沟疝无张力修补均可在局麻下完成，局部麻醉可成为腹股沟疝无张力修补的常规麻醉方式。     

Sequential Myocardial Depressant and Nondepressant Anaesthesia for Coronary Artery Surgery

Patients undergoing coronary artery surgery run a certain risk of developing myocardial infarction in situations with increased myocardial oxygen demand due to e.g. elevations in heart rate and blood pressure. After cardiopulmonary bypass (CPB) there is, however, also the risk of graft occlusion. The present study evaluated the haemodynamic effects of a sequential anaesthesiological technique using halothane 0.5-1.5% in combination with 50% nitrous oxide and droperidol 0.1 mg X kg b.w.-1 before CPB followed by fentanyl 0.2 mg X h-1 in continuous i.v. infusion and diazepam 10-15 mg during and after bypass. Fourteen patients were studied. In seven patients (Group I) halothane was discontinued immediately before CPB and in the following seven patients (Group II) 10-15 min before bypass. The aim was to depress moderately the inotropic state before bypass and to have a normalized myocardial oxygen demand after CPB in order to promote a good flow in the grafts. In Group II mean left ventricular stroke work index (LVSWI) was 0.54-0.79 J X m-2 after bypass as compared to 0.45-0.51 before at comparable filling pressure. Mean left ventricular power index (LVPI) increased from 0.42-0.55 W X m-2 before to 0.73-1.08 after CPB. The patients in Group I showed a similar pattern although with a less marked difference in LVSWI and LVPI values before and after bypass. No correlation was seen between oxygen delivery and oxygen uptake either below or above an oxygen delivery of 15 mmol X min-1 X m-2.     

Effects of Three Anaesthesia Methods on Haemodynamic Responses Connected with the Use of Thigh Tourniquet in Orthopaedic Patients

Haemodynamic changes were studied in 51 patients undergoing orthopaedic surgery of the lower extremity, including exsanguination and thigh tourniquet for longer than 60 min. The patients were randomly divided into three anaesthesia groups: general anaesthesia (including enflurane), epidural anaesthesia (20 ml 0.5% bupivacaine) and spinal anaesthesia (3 ml 0.5% bupivacaine). During the study, five epidural and one spinal patient excluded from haemodynamic comparison required general anaesthesia because of pain from the surgery or ischaemia. In the general anaesthesia group, there was a rise in either systolic or diastolic arterial pressure of over 30% of the control value in 8/15 patients. In the spinal anaesthesia patients, there was a transient rise above 30% in only one patient out of 15 and no rise in the 15 epidural group patients. On the other hand, 11/15 of the epidural patients needed additional analgesics and/or sedation for pain or restlessness. The mean rise in the haemodynamic parameters including CVP was small on inflation of the tourniquet cuff; on deflation there was a mean decrease in CVP of 1-3 cmH2 (0.1-0.3 kPa), the maximum decrease being 8 cmH2O (0.8 kPa). The mean decrease in systolic arterial blood pressure ranged from 2 to 14 mmHg (0.27 to 1.87 kPa) when the cuff was deflated.     

The Effect of Epidural and General Anaesthesia on Lymphocyte Functions during and after Major Orthopaedic Surgery

The blastogenic responses of lymphocytes to PHA-stimulation and lymphocyte lymphokine production have been studied in 27 patients undergoing total hip replacement, operated under either general anaesthesia or epidural anaesthesia. The lymphocytes were isolated from the patients the day before operation, during the operation and on the first postoperative day. The assays were carried out with lymphocytes cultured in medium containing 25% of the patient's serum (Au-medium) and in medium containing 25% of pooled AB+ serum (AB-medium). In the epidural anaesthesia group, the blastogenic response to PHA of lymphocytes incubated in Au-medium increased per- and postoperatively to 132% (n.s.) and 155% (P less than 0.05) compared to preoperative values. In the general anaesthesia group, the PHA-response decreased to 63.7% peroperatively (P less than 0.05) and 88.7% postoperatively (n.s.). When the lymphocytes were incubated in AB-medium, the PHA-response increased in both groups. Lymphocyte lymphokine production in the epidural group was unchanged both per- and postoperatively in both media. However, in the general anaesthesia group there was a reduction in lymphokine activity both per- and postoperatively. This reduction was most pronounced peroperatively when the lymphocytes were incubated in Au-medium (64.2%, P less than 0.05). Control lymphocytes incubated in sera from general anaesthetized patients resulted in significantly lower lymphokine activity (P less than 0.05) in comparison with cultures with sera from patients in the epidural group. These findings indicate a lymphocyte depressing factor in serum from patients operated under general anaesthesia, which is absent during operations in epidural anaesthesia.