The Wide-Awake Approach to Dupuytren’s Disease: Fasciectomy under Local Anesthetic with Epinephrine

The Wide-Awake Approach to Dupuytren's contracture involves fasciectomy under local anesthetic with epinephrine and no tourniquet. The goal of this study is to show that the Wide-Awake Approach produces equivalent outcomes to fasciectomy under general anesthetic with a tourniquet, with fewer risks to the patient. A multicenter retrospective review was conducted on 111 patients with fasciectomies under local or general anesthetic between 2001 and 2007. Data on patient demographics, comorbidities, cost, as well as range of motion was collected and evaluated using Microsoft Excel and SAS. Of 148 fingers, 102 were treated under local and 46 under general anesthetic. The average postoperative Total Active Motion (TAM) for general anesthetic patients was 199.0 ± 29.6 (D5), 223.9 ± 29.3 (D4), 234.6 ± 14.6 (D3), and 246.7 ± 14.4 (D2). The average postoperative TAM for local anesthetic patients was 168.3 ± 62.2 (D5), 195.9 ± 67.5 (D4), 173.0 ± 72.6 (D3), and 177.5 ± 31.8 (D2). There were no significant differences between any of these individual groups (p = 0.09, 0.26, 0.12, and 0.20, respectively); however, when pooled, the overall TAM was significantly greater in the general anesthesia group (222.0 ± 29.7 vs. 186.0 ± 63.0, p = 0.002.). Complication rates and types were similar with both techniques. The Wide-Awake Approach to Dupuytren’s contracture avoids general anesthetic risks and has cost benefits to healthcare providers. Although it yields similar range of motion outcomes to fasciectomy performed under general anesthesia, total active motion may be better with fasciectomy done under general anesthesia.     

Spinal anesthesia using a continuous spinal catheter for cesarean section in a parturient with prior surgical correction of scoliosis

This case report demonstrates the successful anesthetic management of cesarean section for a 29-year-old primiparous parturient with a past history of a scoliosis operation at 13 years of age. An Isola hook and screw-rod system had been implanted as posterior spinal instrumentation at the level of T3-L3. We titrated hyperbaric bupivacaine 7 mg combined with fentanyl 15 μg through a continuous spinal catheter, placed with a catheter-over-needle technique in order to avoid unintentional wide spread of anesthetic agents. The anesthetic level was T4 at the start of the operation. Her surgery was carried out without any problems. Headache, as a dural tap-related complication, was not observed. Spinal anesthesia with the titration of anesthetic agents for cesarean section is considered to be one of the choices for a parturient who has had spinal instrumentation.     

Anesthetic management of an extremely obese patient

We present the case of a morbidly obese woman, with a body mass index (BMI) of 73.7 kg·m⁻², who had a gynecological operation under combined general and epidural anesthesia. The patient's trachea was intubated, using a fiberscope, while she was breathing spontaneously after the intravenous injection of fentanyl and propofol as sedatives. Anesthesia was maintained with intravenous propofol and epidural mepivacaine. When the gynecologist placed a sponge in the abdominal cavity to retract the bowel, the patient experienced severe arterial deoxygenation and mild hypotension, due to massive atelectasis of the left lung. Both oxygenation and perfusion were corrected by the removal of the sponge and with the placement of a pillow under the patient's left shoulder. The atelectasis resulted from compression of the left lung by the fatty mediastinum and by the diaphragm being pushed up by the sponge. The hypotension resulted from impaired venous return and hypoxia. The patient suffered no perioperative complications other than atelectasis and a surgical-site infection. Key factors that contributed to the favorable outcome of this patient included a careful tracheal intubation technique, the choice and dose of anesthetic agents, immediate correction of the factors leading to atelectasis, early ambulation, and prophylaxis for deep vein thrombosis.     

The use of epidural anesthesia and analgesia in aortic surgery.

During a 3-year period, sixty-four consecutive patients, who had elective aortic reconstruction were investigated to determine whether epidural anesthesia and analgesia, combined with light general anesthesia, would lower the rate of perioperative complications in this high-risk group of patients. The epidural group comprised 32 consecutive patients who had surgery during the 20-month period from July 1986 to December 1987. These patients were compared with the previous 32 patients who had aortic reconstruction at Huntington Memorial Hospital (Pasadena, CA) using conventional general anesthetic techniques. Cardiovascular and respiratory morbidity, length of hospital stay, length of intensive care unit stay, and duration of endotracheal intubation were compared. There was no statistically significant difference in cardiovascular morbidity, length of hospital stay, or intensive care unit stay between the two groups. There was however, a striking decrease in respiratory complications and length of intubation in the epidural anesthesia group (P less than 0.005). The authors conclude that epidural anesthesia and analgesia, combined with a light general anesthetic may confer benefits over conventional general anesthesia in patients undergoing aortic surgery.     

Considerations for general anesthesia combined with epidural anesthesia in a patient with stiff-person syndrome

We report the successful management of anesthesia in a patient with stiff-person syndrome (SPS) undergoing a thymectomy using a volatile anesthetic combined with epidural anesthesia. The anesthetic concern in patients with SPS is the possibility of postoperative hypotonia due to the presence of excessive γ-aminobutyric acid (GABA) resulting from an interaction between the anesthetic agents and preoperatively taken therapeutic drugs. Epidural anesthesia has the advantages of decreasing the required amount of anesthetics with GABAergic action, and relieving the postoperative pain that causes the symptoms of SPS. Epidural anesthesia could be a useful technique in SPS patients.     

高位硬膜外麻醉联合臂丛神经阻滞应用于乳腺癌手术临床观察

目的探讨高位硬膜外麻醉联合臂丛神经阻滞用于乳腺癌手术的临床效果。方法对36例接受乳腺癌手术的患者行高位硬膜外麻醉联合臂丛神经阻滞麻醉,回顾性分析临床资料,并对麻醉效果进行总结。结果 36例患者均顺利完成手术,在手术过程中没有出现较为明显的呼吸抑制、神经损伤以及全脊髓麻醉等不良后果。麻醉效果优良率为91.67%。结论高位硬膜外联合臂丛神经阻滞麻醉具有生理干扰小、术后并发症少、可实施硬膜外术后镇痛等优点,应用于乳腺癌手术麻醉的临床效果明显。     

Anesthetic management of concomitant coronary artery bypass grafting without cardiopulmonary bypass and left lower lobectomy

This case report describes an anesthetic management of a patient who received successful concomitant coronary artery bypass grafting without cardiopulmonary bypass and left lower lobectomy. A 66-year-old man presented for left lower lobectomy. His medical history included angina pectoris under control with isosorbide and nifedipine. Preoperative coronary angiography revealed multiple stenosis [100% at right coronary artery (# 2), 99% at left anterodescending artery (# 7) and 90% at left circumflex artery (# 11)]. Concomitant coronary artery bypass grafting without cardiopulmonary bypass and left lower lobectomy were scheduled. Anesthesia was maintained with combined total intravenous anesthesia (propofol and fentanyl) and continuous thoracic epidural anesthesia. Postoperative pain was well controlled with continuous epidural analgesia (TEA) and patient control analgesia (PCA). There were no signs of postoperative respiratory complications and myocardial ischemia. Combined total intravenous and continuous thoracic epidural anesthesia has multiple benefits for concomitant coronary artery bypass grafting without cardiopulmonary bypass and left lower lobectomy.     

Epidural ropivacaine infusion for the treatment of pain following axillary muscle-sparing thoracotomy: a dose-evaluation study

Purpose We aimed to investigate the optimal dose of continuous epidural ropivacaine for effective analgesia with minimal side effects after axillary muscle-sparing thoracotomy. Methods Sixty patients undergoing thoracic surgery via the axillary approach were studied. Patients were given continuous epidural ropivacaine at 6 (group R-6), 9 (group R-9), 12 (group R-12) or 18 mg·h⁻¹ (group R-18) in a randomized double-blinded fashion after surgery. All of the patients received nonsteroidal anti-inflammatory drugs (NSAIDs) every 6 h for 24 h postoperatively. Pain intensity was assessed under three conditions (at rest, on moving, and while coughing), at 4, 8, 16, 24, and 48 h after surgery, and the extent of sensory block was evaluated at the same time points. The ability of a patient to walk unaided was assessed at 24 and 48 h after surgery. Results Pain intensity at rest and coughing was significantly higher in group R-6 than in the other groups at 16 h after surgery. Pain intensity during moving was significantly greater in group R-6 than in groups R-12 and R-18 at 16 h after surgery. Group R-18 exhibited a significantly greater extent of sensory block than the other groups. The number of patients who were not able to walk unaided 24 h after surgery was significantly greater in group R-18. There were no significant differences in the incidences of side effects among the groups. Conclusion Our results showed that epidural analgesia using ropivacaine, at 12 mg·h⁻¹, provided the best analgesia with few side effects.     

Sensorimotor anesthesia and hypotension after subarachnoid block: combined spinal-epidural versus single-shot spinal technique

The extent of the intrathecal compartment depends on the balance between cerebrospinal fluid and subatmospheric epidural pressure. Epidural insertion disrupts this relationship, and the full impact of loss-of-resistance on the qualities of subarachnoid block is unknown. In this study we sought to determine if subarachnoid block, induced by combined spinal-epidural (CSE) using loss-of-resistance to air could render higher sensory anesthesia than single-shot spinal (SSS) when an identical mass of intrathecal anesthetic was injected. Sixty patients, scheduled for minor gynecological procedures, were randomly allocated into three groups all receiving 10 mg of 0.5% hyperbaric bupivacaine. In the SSS group, intrathecal administration was through a 27-gauge Whitacre spinal needle inserted at the L3-4 level. For the CSE group, the epidural space was identified with an 18-gauge Tuohy needle using loss-of-resistance to 4 mL of air. After intrathecal administration, a 20-gauge catheter was left in the epidural space. No further drug or saline was administered through the catheter. The procedure was repeated in group CSE ((no-catheter)) except without insertion of a catheter. Sensorimotor anesthesia was assessed at regular 2.5-min intervals until T10 was reached. In all aspects, there was no difference between CSE and CSE ((no-catheter)). Peak sensory level in SSS was lower than CSE and CSE ((no-catheter)) (median T5 [max T3-min T6] versus (T3 [T1-4] and (T3 [T2-5]) (P < 0.01). During the first 10 min postblock, dermatomal thoracic block was the lowest in SSS (P < 0.05). Time for regression of sensory level to T10 was also shortest in SSS. Hypotension, ephedrine use and period of motor recovery were more pronounced in CSE and CSE ((no-catheter)). We conclude that subarachnoid block induced by CSE produces greater sensorimotor anesthesia and prolonged recovery compared with SSS. There is also a more frequent incidence of hypotension and vasoconstrictor use despite using identical doses and baricity of local anesthetic. IMPLICATIONS: This study confirms that induction of subarachnoid block by a combined-spinal epidural technique produces a greater sensorimotor anesthesia and results in prolonged recovery when compared with a single-shot spinal technique. There is a more frequent incidence of hypotension and vasoconstrictor administration despite identical doses of intrathecally administered local anesthetic.     

Bispectral index during epidural puncture predicts anterograde amnesia in patients given midazolam premedication

Purpose  We hypothesized anterograde amnesia could be predicted by the bispectral index (BIS) during epidural puncture in patients premedicated with intramuscular midazolam. Methods  We investigated 64 consecutive patients undergoing gynecological laparotomy under general anesthesia combined with epidural anesthesia. Midazolam (5 mg) was administered intramuscularly at 15 min before arrival at the operating room. The anesthesiologist informed the patient of the operating room number after evaluating her using the Observer’s Assessment of Alertness and Sedation (OAA/S) scale. A BIS probe was then attached to the patient’s forehead while she was in the lateral position for epidural puncture. Another anesthesiologist interviewed the patient on the day after surgery and asked her the operating room number and whether there was recall of pain. Group A comprised patients with no recall of the room number and no recall of pain during epidural puncture and group R comprised patients who remembered both the room number and the pain. Patients recalling only the room number or the pain were excluded. Results  Forty patients were classified as group A and 20 as group R. Four patients remembered only the room number and they were excluded. There were significant differences in body weight, OAA/S scale on arrival at the operating room, and average BIS, and electromyogram (EMG) values during epidural puncture between the two groups. These four parameters were entered into a multiple logistic regression model for multivariate analysis. The analysis identified the BIS value as the only independent predictor of complete amnesia during epidural puncture. Conclusion  BIS assessment during epidural puncture is informative for the anesthesiologist to predict amnesia following midazolam premedication.     

Inserción intrapleural involuntaria de un catéter epidural en cirugía torácica: ¿está fuera de juego la analgesia regional o existe otra salida?

In thoracic surgery, optimized pain control is crucial to prevent dysfunction in cardiorespiratory mechanics. Epidural anesthesia and paravertebral block are the most popular techniques for analgesia. Unintended intrapleural insertion of an epidural catheter is a rare complication.Our report presents a case of a patient submitted to pulmonary tumor resection by video-assisted thoracoscopic surgery. There was difficulty in epidural insertion related to patient's obesity, but after general anesthesia induction, no additional intravenous analgesia was needed after epidural injection. Surgery required conversion to thoracotomy, with intrapleural identification of epidural catheter. At the end of surgery, surgeons reoriented catheter to paravertebral space, with leak absence confirmation after local anesthetic injection through the catheter. In postoperative period, pain control was efficient, with no complications.It was a successful case that shows that when we find unexpected complications, we can look for alternative solutions to give our patient the best treatment.     

老年患者腹腔镜胆囊切除术的麻醉处理

目的:探讨全身麻醉和全麻复合硬膜外麻醉对老年患者腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)的麻醉效果。方法:30例老年患者行LC,随机分成全麻组(A组,15例)和全麻复合硬膜外麻醉组(B组,15例),分别记录患者入室后、麻醉诱导后、气管插管即刻、切皮、CO2气腹建立后及气管拔管后即刻的收缩压(systolic blood pressure,SBP)、舒张压(diastolic blood pressure,DBP)、心率(heart rate,HR);记录术毕患者苏醒时间、拔管时间和离开手术室时间;拔管后即刻、10min、20min、30min伤口疼痛程度。结果:(1)B组气管插管即刻、CO2气腹后及拔管后即刻的血流动力学较A组稳定,两组比较差异有统计学意义(P<0.05);(2)两组苏醒时间、拔管时间和离室时间差异无统计学意义(P>0.05),但苏醒期间患者发生烦躁反应A组(5例)远高于B组(2例),与A组比较,B组发生烦躁反应发生率较低(13.3%),差异有统计学意义(P<0.05);(3)B组拔管后各时间点VAS评分明显低于A组(P<0.05)。结论:老年患者LC实施硬膜外复合全麻,能减轻术中的应激反应,血流动力学稳定,减轻患者苏醒期疼痛,降低术后烦躁反应发生率,可改善老年患者LC的麻醉效果。     

Vertebral osteomyelitis and epidural abscess after epidural anesthesia for a cesarean section

A 40-year-old woman underwent cesarean section under epidural anesthesia. The anesthetic procedure was carried out in strict aseptic conditions, the catheter was withdrawn 24 hours after surgery, and the patient was discharged 5 days after surgery. She was readmitted with fever, backache, and pain in the lower limbs, with signs of radiculitis but no indication of inflammation or pain at the site of puncture. Magnetic resonance imaging revealed vertebral osteomyelitis at the fifth lumbar and first sacral vertebrae and an epidural abscess with compression of the nerve root. Treatment consisted of 2 g of ceftriaxone daily for 6 weeks, rest, and measures to assure local immobilization. Symptoms gradually improved and no surgical drainage measures were needed. The cause of osteomyelitis was never ascertained. Vertebral osteomyelitis is an unusual event after epidural anesthesia and there have been few opportunities to demonstrate a relationship. Such infections appear spontaneously in immunodepressed patients who undergo diagnostic procedures and treatments that lead to bacteremias with secondary colonization of spinal structures. The topography and characteristics of the infectious lesion, the patient's susceptibility, and the anesthetic procedure and pathogenic agent may help clarify the cause of the osteomyelitis.     

Comparison of epidural anesthesia and general anesthesia for patients with bronchial asthma

We prospectively investigated the incidence of asthmatic attacks in 94 patients (1.5%) who were diagnosed as definite asthma. We separated the patients into three groups: epidural anesthesia (n = 10) including combined spinal/epidural anesthesia (n = 7), combined epidural and general anesthesia (n = 23), and general anesthesia (n = 54). General anesthesia was induced with propofol or midazolam and maintained with N2O and O2 with sevoflurane in adults. Patients who underwent epidural anesthesia and combined spinal and epidural anesthesia showed no asthmatic attacks. The incidence of bronchospasm with combined epidural and general anesthesia was 2/23. The incidence of bronchospasm with general anesthesia was 4/54. Bronchoconstriction occurred after tracheal intubation in 5 patients except in one patient, in whom it occurred after induction of anesthesia with midazolam. All episodes of bronchospasm in the operative period were treated successfully. The frequency of bronchospasm did not depend on the severity of asthmatic symptoms or the chronic use of bronchodilators before operation. These findings suggest that tracheal intubation, not the choice of anesthetic, plays an important role in the pathogenesis of bronchospasm.     

Epidural hematoma unrelated to combined spinal-epidural anesthesia in a patient with ankylosing spondylitis receiving aspirin after total hip replacement

Although rare, major complications after spinal and epidural anesthesia do occur. The safety of spinal and epidural anesthesia has been well established. This is a report of an epidural hematoma in a patient with ankylosing spondylitis who received aspirin for thromboprophylaxis after total hip replacement that was unrelated to the combined spinal-epidural anesthetic. Most epidural hematomas are spontaneous and idiopathic.     

Usefulness of oral hypnotic premedication for volatile induction of anesthesia in adults

Purpose. We investigated the effects of oral hypnotic premedication for smooth anesthetic induction and for the patient's comfort under anesthesia, using sevoflurane without nitrous oxide. Methods. Adult patients were divided into four groups: control (n= 12), triazolam (0.25 mg; n= 12), zopiclone (7.5 mg; n= 12), and clonidine (0.15 mg; n= 12) groups. Each premedication was given to each patient 1 h before the anesthesia. The patients breathed out to residual volume and then the anesthetic mask was fitted. The repeated vital capacity breathing technique was used, with 5% sevoflurane in 10 l·min⁻¹ oxygen. Induction time, specific induction side effects, and acceptability of this technique by the patients were recorded by an independent observer. Results. Induction time in the premedicated groups ranged from 66 ± 12 s (mean ± SD) to 76 ± 14 s, and these values were significantly shorter than that in the control group (92 ± 16 s). The number of patients in whom adverse effects occurred during anesthetic induction was significantly greater in the control group (4 patients; 33%) than in the premedicated groups (1 patient each; 8%). Acceptability of the smell of sevoflurane was significantly higher in the premedicated groups (8–10 patients; 67%–83%) than in the control group (5 patients; 42%). Conclusion. Oral hypnotic premedications with either triazolam (0.25 mg), zopiclone (7.5 mg), or clonidine (0.15 mg) are recommended for smoother volatile anesthetic induction and for the patient's comfort in adults. Received: January 28, 2002 / Accepted: April 26, 2002     

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     

Anterior spinal artery syndrome after minimally invasive direct coronary artery bypass grafting under general combined epidural anesthesia

A 65-year-old patient with ischemic heart disease and severe diabetes mellitus underwent minimally invasive direct coronary artery bypass grafting under general combined with epidural anesthesia. Paraplegia developed after surgery and the diagnosis of anterior spinal artery syndrome was made based on the patient s neurological condition and magnetic resonance imaging findings. Paraplegia following epidural anesthesia is a rare but recognized complication and this complication should be taken into account, especially in patients at risk, when considering epidural analgesia techniques in the minimally invasive cardiac surgery.     

Epidural anesthesia and analgesia are not impaired after dural puncture with or without epidural blood patch.

Previous reports have noted a decrease in the success of subsequent epidural anesthesia and analgesia in patients who have undergone prior dural puncture with or without an epidural blood patch. Our retrospective study evaluated the success of epidural anesthesia and analgesia in all patients at the Mayo Clinic who had received a prior epidural blood patch over a 12-yr period. Each epidural blood patch patient was matched to two patients undergoing epidural anesthesia after previous dural puncture (without epidural blood patch) and to two patients undergoing epidural anesthesia after previous epidural anesthetic (without dural puncture/blood patch). These patients were matched for the duration of time between the initial procedure and subsequent epidural anesthetic and the indication (surgery, labor analgesia, postoperative analgesia) for which the subsequent epidural was performed. Subsequent epidural anesthesia was successful in 28 of 29 (96.6%, exact 95% CI 82.2%-99.9%) patients who had undergone prior blood patch, 55 of 58 (94.8%, 85.6%-98.9%) patients with a history of dural puncture, and 55 of 58 (94.8%, 85.6%-98.9%) patients who had had previous epidural anesthesia. There was no significant difference in the success rate of subsequent epidural anesthesia among groups. We conclude that prior dural puncture, with or without epidural blood patch, does not affect the success rate of subsequent epidural anesthesia. Implications: Patients with postdural puncture headache should not be denied the benefits of an epidural blood patch because of concerns about the impairment of subsequent epidural anesthetics. The success rate of subsequent epidural anesthesia and analgesia in patients who have undergone dural puncture with or without epidural blood patch is similar to that of patients who have undergone two prior epidural anesthetics.     

Coronary artery bypass grafting via sternotomy in conscious patients

Abstract The application of high thoracic epidural anesthesia (TEA) as an adjunct to general anesthesia is increasingly being used for coronary artery bypass grafting (CABG) with extracorporeal circulation. Recent developments in beating heart techniques rendered the sole use of TEA in conscious patients possible, and have been reported for single-vessel beating heart CABG via lateral thoracotomy. For multi-vessel revascularization, the heart is usually approached via sternotomy; therefore, the sole use of TEA was applied in awake patients who underwent CABG via sternotomy. A total of 7 patients scheduled for awake coronary artery bypass grafting (ACAB) received TEA via an epidural catheter placed at the levels of T1–2 or T2–3, respectively. Total arterial myocardial revascularization was performed after partial lower sternotomy. Besides standard monitoring, anesthetic levels were determined using an epidural scoring scale for arm movements (ESSAM). While 6 patients were awake and spontaneously breathing during the entire procedure, one patient had to be intubated intraoperatively because of respiratory distress caused by phrenic nerve palsy. Hemodynamics were stable throughout the operation. No significant arterial hypercarbia occurred. All patients rated TEA as “good” or “excellent.” We could demonstrate that the single use of TEA for CABG via sternotomy was feasible and that the patients felt well, were painfree, and remained hemodynamically stable. High patient satisfaction in our small and highly selected cohort can be reported. Because beating heart surgery in a conscious patient still carries a significant risk, further randomized controlled trials are mandatory to definitively evaluate the role of sole TEA in cardiac surgery. Electronic Publication