Tumescent local anesthesia for the surgical treatment of burns and postburn sequelae in pediatric patients

BACKGROUND: Tumescent local anesthesia is a technique for regional anesthesia of the skin and the subcutaneous tissue, using infiltration of large volumes of local anesthetic. The advantages of this technique are (1) simplicity, (2) prolonged postoperative analgesia, (3) low incidence of bleeding, and (4) anesthetization of a large area of the body. There are no reports on the use of tumescent local anesthesia in pediatric patients. METHODS: In 30 consecutive pediatric burn patients with American Society of Anesthesiologists physical status class I or II who were 1-120 months old (34 +/- 31.6 months), after induction of anesthesia with nitrous oxide-oxygen-sevoflurane, infiltration with 0.05% (14 ml/kg) or 0.1% (7 ml/kg) lidocaine solution was performed. Anesthesia was maintained with patients spontaneously breathing with 1.5% sevoflurane in nitrous oxide-oxygen (50%). The maximum dose of lidocaine used was 7 mg/kg. Postoperative pain was assessed by using the Children's Hospital of Eastern Ontario Pain Scale (for patients aged up to 5 yr) and by using a visual analog scale (for patients older than 5 yr). A comparison with a historic control group not treated with the tumescent local anesthesia technique was performed. RESULTS: No patients were excluded from the study, and no significant variations in the monitored intraoperative parameters were observed. Five patients had an increase in heart rate and respiratory rate at the beginning of surgery, and of these, two needed a temporary increase in sevoflurane concentration. After the initial incision, no response to painful stimulus was observed. No complications occurred. Six patients required postoperative acetaminophen administration, and 24 patients did not require analgesic treatment. CONCLUSIONS: Tumescent local anesthesia with maximum dose of 7 mg/kg lidocaine seems to be safe and the sole possible effective locoregional anesthesia technique for the surgical treatment of noncontiguous pediatric burns.     

Epidural lidocaine decreases sevoflurane requirement for adequate depth of anesthesia as measured by the Bispectral Index monitor

BACKGROUND: Epidural anesthesia potentiates sedative drug effects and decreases minimum alveolar concentration (MAC). The authors hypothesized that epidural anesthesia also decreases the general anesthetic requirements for adequate depth of anesthesia as measured by Bispectral Index (BIS). METHODS: After premedication with 0.02 mg/kg midazolam and 1 microg/kg fentanyl, 30 patients aged 20-65 yr were randomized in a double-blinded fashion to receive general anesthesia with either intravenous saline placebo or intravenous lidocaine control (1-mg/kg bolus dose; 25 microg x kg(-1) x min(-1)). A matched group was prospectively assigned to receive epidural lidocaine (15 ml; 2%) with intravenous saline placebo. All patients received 4 mg/kg thiopental and 1 mg/kg rocuronium for tracheal intubation. After 10 min of a predetermined end-tidal sevoflurane concentration, BIS was measured. The ED50 of sevoflurane for each group was determined by up-down methodology based on BIS less than 50 (MAC(BIS50)). Plasma lidocaine concentrations were measured. RESULTS: The MAC(BIS50) of sevoflurane (0.59% end tidal) was significantly decreased with lidocaine epidural anesthesia compared with general anesthesia alone (0.92%) or with intravenous lidocaine (1%; P < 0.0001). Plasma lidocaine concentrations in the intravenous lidocaine group (1.9 microg/ml) were similar to those in the epidural lidocaine group (2.0 microg/ml). CONCLUSIONS: Epidural anesthesia reduced by 34% the sevoflurane required for adequate depth of anesthesia. This effect was not a result of systemic lidocaine absorbtion, but may have been caused by deafferentation by epidural anesthesia or direct rostral spread of local anesthetic within the cerebrospinal fluid. Lower-than-expected concentrations of volatile agents may be sufficient during combined epidural-general anesthesia.     

Lidocaine Levels During the First Two Hours of Infiltration of Dilute Anesthetic Solution for Tumescent Liposuction: Rapid Versus Slow Delivery

BACKGROUND: Tumescent anesthesia for liposuction with dilute lidocaine has been well documented to result in peak serum levels 4-14 hours after infiltration. Pharmacokinetic studies have shown that the rate of lidocaine absorption is related not only to dilution, but also to the speed of subcutaneous infiltration. Early studies with a more concentrated solution of lidocaine (1.0%) have shown that with rapid infusion, peak plasma levels may occur within 30 minutes. OBJECTIVE: To determine whether rapid absorption of lidocaine may occur during infusion of tumescent solution by varying the rate of infusion of dilute lidocaine solution (0.05% or 0.1%) and observing serum levels of lidocaine within the first 2 hours of the procedure. METHODS: Eighteen patients participated in this study and were infused with a standard liposuction tumescent formula consisting of lidocaine either 0.05% or 0.1%. The rates of infusion of tumescent anesthesia ranged from 27.1 mg/min up to 200 mg/min infused over a period of 5 minutes to 2 hours. Total lidocaine infused ranged from 7.4 to 57.7 mg/kg. Serum levels of lidocaine were taken every 15 minutes during the first hour of the procedure and repeated at 2 hours. RESULTS: In all 18 patients, lidocaine levels remained significantly below the toxic range and were always less than 2.0 microgram/ml. In 11 patients, lidocaine levels at all time intervals were less than 0.5 microgram/ml. In seven patients, the lidocaine levels ranged from 0.6 to 1.9 microgram/ml at varying intervals. There was no correlation between the maximum dose of lidocaine (mg/kg) or rate of lidocaine delivered (mg/ml) with plasma levels of lidocaine. CONCLUSION: Despite variability, the serum levels of lidocaine remained well within safety limits during infusion of tumescent solution and the first hours of the procedure when infused in rates up to 200 mg/min with spinal needles and/or small diameter multiholed infusion cannulas.     

When One Liter Does Not Equal 1000 Milliliters: Implications for the Tumescent Technique

BACKGROUND: Tumescent anesthesia has revolutionized the practice of liposuction. Inherent to the tumescent technique is the use of large volumes of dilute solutions of lidocaine with epinephrine instilled into subcutaneous fat deposits. Precise formulation of the tumescent anesthesia is essential to liposuction technique. OBJECTIVES: To determine the actual volumes of fluids contained in intravenous (IV) 1 L bags of saline used for tumescent anesthesia, to calculate volumes supplied in 50 cc stock solutions of 1% lidocaine, and to measure the amount of fluid retained by peristalic pump tubing used for infiltration. METHODS: The amount of saline contained in fifteen 1 L saline bags from three different manufacturers was calculated using graduated cylinder methodology. The volume of tumescent anesthesia retained by peristaltic pump tubing was calculated by expelling the contents of the filler tubing and measuring it. The actual amount of 1% lidocaine contained within fifteen 50 ml "stock" 1% lidocaine bottles from different manufacturers and with different lot numbers was calculated by transferring the contents into graduated cylinders. RESULTS: One liter IV bags of physiologic saline contained an average volume of 1051 ml (range 1033-1069 ml). The 50 ml bottles of 1% lidocaine with epinephrine contain an average of 54 ml of anesthetic (range 52.5-55 ml). Infusion tubing for use with peristaltic pumps may retain 46-146 ml of tumescent anesthesia. CONCLUSION: One liter IV bags of normal saline contain more than 1 L, having an average volume of 1051 ml. Common methods of preparation of 0.05% lidocaine with 1:1,000,000 epinephrine and sodium bicarbonate can increase the total amount of fluid in the tumescent anesthesia to 1112 ml for 0.05% solutions and preparation of a 0.1% solution contains an average volume of 1162 ml. The fluid contained in each bag may be increased over labeling by as much as 11-16%. Final concentrations of lidocaine in tumescent anesthesia may be reduced due to extra fluids. A 0.05% lidocaine solution may have a final lidocaine concentration of 0.045% and a 0.1% lidocaine solution may have an actual concentration of 0.086%. Lidocaine concentrations may be reduced by as much as 10-14%. Extra anesthesia fluid is also contained within stock 50 ml bottles of 1% lidocaine. Dermatologic surgeons should be aware of extra fluid possibly contained within tumescent anesthetic preparation, be aware of the extra anesthesia supplied in standard 1% lidocaine bottles, and possible decreased concentration of lidocaine within the final tumescent anesthesia.     

Epidural Lidocaine Decreases Sevoflurane Requirement for Adequate Depth of Anesthesia as Measured by the Bispectral Index ® Monitor

Background: Epidural anesthesia potentiates sedative drug effects and decreases minimum alveolar concentration (MAC). The authors hypothesized that epidural anesthesia also decreases the general anesthetic requirements for adequate depth of anesthesia as measured by Bispectral Index (BIS).

Methods: After premedication with 0.02 mg/kg midazolam and 1 [mu]g/kg fentanyl, 30 patients aged 20-65 yr were randomized in a double-blinded fashion to receive general anesthesia with either intravenous saline placebo or intravenous lidocaine control (1-mg/kg bolus dose; 25 [mu]g [middle dot] kg-1 [middle dot] min-1). A matched group was prospectively assigned to receive epidural lidocaine (15 ml; 2%) with intravenous saline placebo. All patients received 4 mg/kg thiopental and 1 mg/kg rocuronium for tracheal intubation. After 10 min of a predetermined end-tidal sevoflurane concentration, BIS was measured. The ED50 of sevoflurane for each group was determined by up-down methodology based on BIS less than 50 (MACBIS50). Plasma lidocaine concentrations were measured.

Results: The MACBIS50 of sevoflurane (0.59% end tidal) was significantly decreased with lidocaine epidural anesthesia compared with general anesthesia alone (0.92%) or with intravenous lidocaine (1 %;P < 0.0001). Plasma lidocaine concentrations in the intravenous lidocaine group (1.9 [mu]g/ml) were similar to those in the epidural lidocaine group (2.0 [mu]g/ml).     

A comparison of liver function after hepatectomy in cirrhotic patients between sevoflurane and isoflurane in anesthesia with nitrous oxide and epidural block

In this study, we compared postoperative liver function in patients with liver cirrhosis between isoflurane and sevoflurane anesthesia with nitrous oxide (N(2)O) and epidural block. Forty cirrhotic patients with Child-Pugh Grade A, aged 40 to 70 yr, scheduled for liver segmentectomy, had anesthesia induced with midazolam 0.1 mg/kg and fentanyl 4 micro g/kg. For maintenance, intermittent epidural administration of 1.5% lidocaine 4 to 6 mL and sevoflurane (sevoflurane group) or isoflurane (isoflurane group) with N(2)O 3 L/min in oxygen 3 L/min was used. Aspartate aminotransferase, alanine aminotransferase, total bilirubin, alkaline phosphatase, choline esterase, albumin, prothrombin time, and platelet count were measured before and 1, 3, and 7 days after surgery. Aspartate aminotransferase, alanine aminotransferase, and alkaline phosphatase increased significantly, with the peaks at 3 days after surgery in both groups. The increases in these variables were significantly larger in the isoflurane group than those in the sevoflurane group. No patient developed hepatic failure. All increases in liver enzymes were small and of questionable clinical relevance. Whether sevoflurane might be a better anesthetic when combined with N(2)O and epidural block for cirrhotic patients than isoflurane with respect to liver damage remains to be determined. IMPLICATIONS: In cirrhotic patients with Child-Pugh Grade A, isoflurane induced more of an increase in serum concentrations of liver enzymes after surgery than sevoflurane when combined with nitrous oxide and epidural block. However, the increases were small, and there was no clinical liver damage.     

双侧大腿环形吸脂术中肿胀麻醉利多卡因用量分析

目的:探讨局部肿胀麻醉技术下进行双侧大腿环形吸脂手术中利多卡因用量及是否存在中毒反应。方法:148例全部为女性,年龄19～56岁,平均(30.01±7.91)岁,肥胖指数13.43～43.59,平均23.37±6.82。采用左大腿前、右大腿前、左大腿后、右大腿后侧四个部位环形序贯吸脂术,统计手术中肿胀液的注射量、利多卡因用量以及吸出脂肪和肿胀液数量。连续观察术中、术后病人的临床反应和生命体征。结果:肿胀液注入皮下脂肪数量为3000～9000ml,平均(6009.80±1482.51)ml。吸出皮下脂肪数量1500～7000ml,平均(3105.74±1068.24)ml。术中抽出肿胀液200～3300ml,平均(1312.50±549.92)ml,约占注入量的5%～41.67%,平均(21.84±6.95)%。注入皮下脂肪之利多卡因剂量为27.69～88.42mg/kg,平均(59.45±13.62)mg/kg。术中出血极少,生命体征稳定,术中及术后未见眩晕、耳鸣、幻听、金属味、口周麻木、定向障碍、抽搐、惊厥等利多卡因药物中毒的临床症状。术后站立包扎时个别患者有体位性低血压表现,平卧即可恢复正常。术后大腿围径和形态均有不同程度改善,效果满意。结论:在双侧大腿环形吸脂手术中,采用分部位序贯吸脂方法,可以有效避免利多卡因中毒发生,达到安全有效的结果。     

吸脂术中大剂量使用利多卡因的血药浓度监测及意义

目的探讨作为局部麻醉剂的利多卡因在肿胀法脂肪抽吸术中的极限剂量是多少,既能达到良好的镇痛效果,又能安全地使用而不产生毒副作用。方法对１４例大剂量使用低浓度利多卡因作为局麻药的脂肪抽吸术的术中和术后血清利多卡因浓度以免疫荧光测定法进行了动态监测,作出其时间浓度曲线,并与临床表现相对照。结果在此类手术中,利多卡因在０１ｍｇ／ｍｌ的浓度下,加入１／１百万～１／２百万肾上腺素,其用量可达３５ｍｇ／ｋｇ体重而血清高峰浓度仍在安全范围内,无中毒症状,既可减轻病人的疼痛,又可减少出血,提高安全性,增加脂肪抽吸量。结论本研究为肿胀法吸脂术中大剂量使用利多卡因的临床实践提供了理论依据。     

吸脂术中大剂量使用利多卡因的血药浓度监测及意义

目的 探讨作为局部麻醉剂的利多卡因在肿胀法脂肪抽吸术中的有限剂量是多少，既能达到良好的镇痛效果，又有安全地使用而不产生毒副作用。方法 对１４例大剂量使用低浓度利多卡因作为局麻药的脂肪抽吸术的术中和术后血清利多卡因浓度以免疫荧光测定法进行了动态监测，作出其时间－浓度曲线，并与临床表现相对照。结果 在此类手术中，利多卡因在０．１ｍｇ／ｍｌ的浓度下，加入１／１百万￣１／２百万肾上腺素，其用量可达３５ｍｇ     

Pediatric caudal block with mepivacaine, bupivacaine or a mixture of both drugs: requirement for postoperative analgesia and plasma concentration of local anesthetics

STUDY OBJECTIVES: To assess the effects of pediatric caudal block using mepivacaine, bupivacaine, or a mixture of both drugs on postoperative analgesia, and to examine plasma concentrations of the local anesthetics after caudal injection. DESIGN: Prospective, randomized, double-blind study. SETTING: Operating room and pediatric surgical ward. PATIENTS: 60 ASA physical status I children weighing 10 to 20 kg (26 females, 34 males), and scheduled for inguinal herniorrhaphy. INTERVENTIONS: Patients randomly received caudal block with 1 mL/kg of mepivacaine 1% (Group M, n = 20), 1 mL/kg of bupivacaine 0.25% (Group B, n = 20), or a mixture of 0.5 mL/kg of mepivacaine 1% and 0.5 mL/kg of bupivacaine 0.25% (Group MB, n = 20) after induction of anesthesia with sevoflurane in 50% oxygen (O2). Anesthesia was maintained with 66% nitrous oxide in O2 supplemented with sevoflurane at an end-tidal concentration of less than 1%. MEASUREMENTS AND MAIN RESULTS: Postoperative pain scores using a pediatric pain scale and plasma concentration of each local anesthetic were measured. In Group M, four patients required postoperative analgesics within the first 24 hours. However, no patients required postoperative analgesics in Groups B and MB. In Group M, the plasma concentration of mepivacaine of two patients exceeded 5 microg/kg of the level of toxicity. However, these patients did not show any toxic symptoms. Because a mixture of two local anesthetics halves the concentration of each local anesthetic, the plasma concentrations of mepivacaine and bupivacaine in Group MB were significantly lower than those of Groups M and B. CONCLUSIONS: Pediatric caudal block with a mixture of mepivacaine and bupivacaine is effective for intraoperative and postoperative analgesia.     

Comparison of the costs and recovery profiles of three anesthetic techniques for ambulatory anorectal surgery

BACKGROUND: Given the current practice environment, it is important to determine the anesthetic technique with the highest patient acceptance and lowest associated costs. The authors compared three commonly used anesthetic techniques for anorectal procedures in the ambulatory setting. METHODS: Ninety-three consenting adult outpatients undergoing anorectal surgery were randomly assigned to one of three anesthetic treatment groups: group 1 received local infiltration with a 30-ml mixture containing 15 ml lidocaine, 2%, and 15 ml bupivacaine, 0.5%, with epinephrine (1:200,000) in combination with intravenous sedation using a propofol infusion, 25-100 microg. kg-1. min-1; group 2 received a spinal subarachnoid block with a combination of 30 mg lidocaine and 20 microg fentanyl with midazolam, 1-2-mg intravenous bolus doses; and group 3 received general anesthesia with 2.5 mg/kg propofol administered intravenously and 0.5-2% sevoflurane in combination with 65% nitrous oxide. In groups 2 and 3, the surgeon also administered 10 ml of the previously described local anesthetic mixture at the surgical site before the skin incision. RESULTS: The mean costs were significantly decreased in group 1 ($69 +/- 20 compared with $104 +/- 18 and $145 +/- 25 in groups 2 and 3, respectively) because both intraoperative and recovery costs were lowest (P < 0.05). Although the surgical time did not differ among the three groups, the anesthesia time and times to oral intake and home-readiness were significantly shorter in group 1 (vs. groups 2 and 3). There was no significant difference among the three groups with respect to the postoperative side effects or unanticipated hospitalizations. However, the need for pain medication was less in groups 1 and 2 (19% and 19% vs. 45% for group 3; P < 0.05). Patients in group 1 had no complaints of nausea (vs. 3% and 26% in groups 2 and 3, respectively). More patients in group 1 (68%) were highly satisfied with the care they received than in groups 2 (58%) and 3 (39%). CONCLUSIONS: The use of local anesthesia with sedation is the most cost-effective technique for anorectal surgery in the ambulatory setting.     

Comparison of the Costs and Recovery Profiles of Three Anesthetic Techniques for Ambulatory Anorectal Surgery

Background: Given the current practice environment, it is important to determine the anesthetic technique with the highest patient acceptance and lowest associated costs. The authors compared three commonly used anesthetic techniques for anorectal procedures in the ambulatory setting.

Methods: Ninety-three consenting adult outpatients undergoing anorectal surgery were randomly assigned to one of three anesthetic treatment groups: group 1 received local infiltration with a 30-ml mixture containing 15 ml lidocaine, 2%, and 15 ml bupivacaine, 0.5%, with epinephrine (1:200,000) in combination with intravenous sedation using a propofol infusion, 25-100 [mu]g [middle dot] kg-1 [middle dot] min-1; group 2 received a spinal subarachnoid block with a combination of 30 mg lidocaine and 20 [mu]g fentanyl with midazolam, 1-2-mg intravenous bolus doses; and group 3 received general anesthesia with 2.5 mg/kg propofol administered intravenously and 0.5-2% sevoflurane in combination with 65% nitrous oxide. In groups 2 and 3, the surgeon also administered 10 ml of the previously described local anesthetic mixture at the surgical site before the skin incision.

Results: The mean costs were significantly decreased in group 1 ($69 +/- 20 compared with $104 +/- 18 and $145 +/- 25 in groups 2 and 3, respectively) because both intraoperative and recovery costs were lowest (P < 0.05). Although the surgical time did not differ among the three groups, the anesthesia time and times to oral intake and home-readiness were significantly shorter in group 1 (vs. groups 2 and 3). There was no significant difference among the three groups with respect to the postoperative side effects or unanticipated hospitalizations. However, the need for pain medication was less in groups 1 and 2 (19% and 19%vs. 45% for group 3;P < 0.05). Patients in group 1 had no complaints of nausea (vs. 3% and 26% in groups 2 and 3, respectively). More patients in group 1 (68%) were highly satisfied with the care they received than in groups 2 (58%) and 3 (39%).     

不同麻醉方法对老年结直肠癌手术患者白细胞糖代谢的影响

目的 评价不同麻醉方法对老年结直肠癌患者白细胞糖代谢的影响.方法择期拟行结直肠癌手术患者50例,年龄≥65岁,体重指数18～25 kg/m3,ASA分级Ⅰ或Ⅱ级,采用随机数字表法,将患者随机分为七氟醚吸入全麻组(Sevo组)和七氟醚吸入全麻联合硬膜外阻滞组(S+E组),每组25例.S+E组入室后硬膜外穿刺置管,给予2%利多卡因3 ml,5 min后确认无腰麻征象,给予1%利多卡因和0.2%丁卡因混合液8～10ml,每隔50min追加4～5ml.术中患者呼气末七氟醚浓度S+E组维持0.7 MAC,Sevo组维持1.0 MAC,根据BIS值监测调整麻醉深度.分别于麻醉前10 min(T1)、手术结束后60 min(T2)、24 h(T3)和5 d(T4)时采集外周静脉血,计数白细胞,检测白细胞内丙酮酸激酶(PK)和葡萄糖6-磷酸脱氢酶(C6PD)的活性.结果 与T1时比较,两组T3时白细胞计数均升高,S+E组T3时白细胞内PK活性、Sevo组T3时、S+E组T3,4时白细胞内G6PD活性升高(P＜0.01);与Sevo组比较,S+E组T3时白细胞内PK活性、T3,4时白细胞内G6PD活性升高(P＜0.05),白细胞计数差异无统计学意义(P＞0.05).结论 两种麻醉方法用于老年结直肠癌手术患者时白细胞计数无明显差别,但七氟醚吸入全麻联合硬膜外阻滞较单纯吸人七氟醚全麻时老年患者白细胞功能增强.

Abstract：

Objective To evaluate the influence of different methods of anesthesia on the glucose metabolism of leukocytes in elderly patients undergoing colorectal cancer surgery. Methods Fifty ASA Ⅰ or Ⅱ patients, aged≥65 yr, with body mass index 18-25 kg/m2, scheduled for elective colorectal cancer surgery, were randomly divided into 2 groups ( n = 25 each) : sevoflurane anesthesia group (Sevo group) and sevoflurane anesthesia combined with epidural block group ( S + E group) . The patients in S + E group underwent epidural catheterization, and 2% lidocaine 3 ml was given via the epidural catheter. If no signs of spinal anesthesia were confirmed 5 min later, the mixture of 1% lidocaine and 0.2% tetracaine 8-10 ml was given, and an increment of the mixture 4-5 ml was given every 50 min. During the operation, the end-tidal concentration of sevoflurane was maintained at 0.7 MAC in S + E group and at 1.0 MAC in Sevo group. The depth of anesthesia was adjusted according to the BIS value in both groups. Venous blood samples were taken at 10 min before operation (T1 ), and 60 min, 24 h.and 5 days after the end of operation (T2-4 ) for WBC count and measurement of activities of pyruvate kinase (PK)and glucose-6-phosphate dehydrogenase (G6PD) in the leukocytes. Results Compared with T1, the WBC count at T3 in both groups, the PK activity at T, in group S+E and G6PD activity at T, in group Sevo and at T3,4 in group S + E were significantly increased ( P ＜ 0.01) . Compared with group Sevo, the PK activity at T, and G6PD activity at T3,4 were significantly increased in group S+E ( P ＜ 0.05) . There was no significant difference in the WBC count between the two groups ( P ＞ 0.05) . Conclusion There is no significant change in the WBC count when the two methods of anesthesia are used in elderly patients undergoing colorectal caner surgery, however, sevoflurane anesthesia combined with epidural block enhances the leukocyte function in elderly patients compared with sevoflurane anesthesia alone.     

Propofol or sevoflurane anesthesia without muscle relaxants allow the early extubation of myasthenic patients

PURPOSE: To compare two non-muscle relaxant anesthetic techniques in myasthenic patients undergoing trans-sternal thymectomy, evaluating the intra- and postoperative conditions including the early extubation in the operating room. METHODS: Sixty-eight consecutive myasthenic patients undergoing trans-sternal thymectomy were prospectively randomized in two groups: propofol and sevoflurane. In both groups anesthesia was induced with propofol (1-2 mg x kg(-1)) and intubation performed after topical anesthesia of the airway with lidocaine. Anesthesia was maintained in the propofol group (36 patients) with a continuous propofol infusion (3-6 mg x kg(-1) x hr(-1)) and nitrous oxide and, in the sevoflurane group (32 patients), with sevoflurane (end-tidal 1-1.5%) in O2:N2O. Intubating conditions, hemodynamic changes, neuromuscular transmission, postoperative intensive care unit and hospital length of stay and complications were evaluated. Data were analyzed with repeated measure two-way analysis of variance (ANOVA), Chi square test and Student's t test. RESULTS: Intubating conditions were good in all patients. There were no hemodynamic changes. All patients were extubated in the operating room and none had to be re-intubated for postoperative respiratory depression. Neuromuscular transmission showed minimal changes, more important in the sevoflurane group, and at the end of the procedure the recovery was complete in all patients. We did not observe any other significant differences between the two groups studied. CONCLUSION: Our data show that these two anesthetic techniques allow the early extubation of myasthenic patients in the operating room.     

低浓度利多卡因肿胀麻醉在体表大面积病变组织切除中的应用

目的：探讨低浓度利多卡因肿胀麻醉在体表大面积病变组织切除手术中的应用效果。方法：对22例体表大面积病变,其中神经纤维瘤11例、下肢淋巴水肿2例、巨痣9例,应用含0.02%利多卡因的低浓度肿胀麻醉技术,将病变组织完整或大部切除,观察其临床效果。结果：所有病例术中麻醉满意、出血少、手术时间缩短、术后早期疼痛轻。结论：在体表大面积病变组织切除手术中局部注射低浓度肿胀液,术中出血少、降低了手术风险、术后恢复快,是一种简便、安全、有效的方法。     

Sevoflurane requirements to suppress responses to transcutaneous electrical stimulation during epidural anesthesia with 0.5% and 1% lidocaine

We sought to determine general anesthetic requirements to suppress skin vasomotor reflex (SVmR) and pupillary dilation (PD) in response to transcutaneous electrical stimulation (TES) during combined epidural-general anesthesia. Thirty-five patients undergoing lower abdominal surgery were randomly divided into 2 groups to epidurally receive 0.5% (Group 1) or 1% lidocaine (Group 2) with sevoflurane anesthesia. A bolus injection of either lidocaine was followed by the infusion of the same solution, and the central dermatomal level of loss of cold sensation (C) was determined. After the induction of general anesthesia with 5% sevoflurane and 67% nitrous oxide, nitrous oxide was discontinued, and sevoflurane concentration was decreased. TES was given at both site C and site three dermatomal segments (U) cephalad to C to determine the end-tidal sevoflurane concentration required to suppress SVmR and PD. End-tidal sevoflurane concentration that suppressed both responses was larger in Group 1 than in Group 2 at both sites and was larger at site U than at site C in both groups. We conclude that sevoflurane requirements to suppress SVmR and PD in response to TES during combined epidural-general anesthesia are different depending on the concentration of lidocaine and the site where surgical stimulation is applied. IMPLICATIONS: We evaluated sevoflurane requirements to suppress skin vasomotor reflex and pupillary dilation in response to a transcutaneous electrical stimulation at the surgical site during combined epidural-general anesthesia. Our results indicate that when epidural anesthesia is combined, general anesthetic requirements decrease depending on the lidocaine concentration for epidural anesthesia and the site where surgical stimulation is applied.     

Total mastectomy under local anesthesia: the tumescent technique

The management of breast cancer in elderly women is controversial. Breast cancer in this age group tends to be biologically less aggressive and is highly responsive to hormonal intervention. The risk of dying of other causes often exceeds the risk of cancer recurrence. For these reasons, older patients tend to be treated less aggressively. One large study of elderly women with breast cancer found that half of the patients were undertreated. Four patients (mean age 72 years, range 61-95 years) underwent a unilateral total mastectomy for cancer under local anesthesia using the tumescent technique of infiltrating dilute lidocaine with epinephrine (25 ml of 1% lidocaine [250 mg] and 1 ml of 1:1000 epinephrine [1 mg] to 1 L of Ringers lactate) via an infusion pump. Three of the patients had estrogen receptor (ER)-negative tumors and one patient had tumor progression despite switching from tamoxifen to anastrozole. All four patients were class IV as defined by the American Society of Anesthesiology (ASA). There was no morbidity related to the surgery in the form of hematoma, wound infection, or skin flap necrosis. The patients were discharged 1-4 days after surgery. The anesthesia was adequate in all four cases and there was no deviation from the described technique. The mean operative time was 35 minutes (range 24-46 minutes). The tumescent technique is a safe, effective method for performing a total mastectomy in patients who would not be considered candidates for general anesthesia.     

Pre-incision infiltration with lidocaine reduces pain and opioid consumption after reduction mammoplasty

Background and Objectives. To determine the analgesis efficacy of preoperative tumescent infiltration with lidocaine for reduction mammoplasty. Methods. Women with mammary hypertrophy were randomly allocated to one of two study groups in a double-blind clinical trial. Patients in group 1 received preincision infiltration with 5 mL/kg of 0.35% lidocaine with 1:1,000,000 epinephrine into each breast after induction of general anesthesia. Group 2 patients received similar injections of 5 mL/kg of saline with 1:1,000,000 epinephrine. Intravenous patient-controlled analgesia (PCA) morphine (1.0 mg bolus with 5-minute lockout) was available for 9.5 hours in the postoperative period. Visual analog pain scores were recorded during the postoperative period, and hourly morphine consumption data were retrieved from the PCA apparatus. Fitness for discharge was evaluated by the postanesthesia care unit nurse using standardized discharge criteria. Results. Visual analog pain scores were higher in group 2 patients until 3.5 hours after surgery. Patients in the saline group had higher intravenous morphine consumption during all 1-hour postoperative intervals, although the differences between groups were statistically significant only until 4.5 hours after the operation. Total intravenous morphine consumption during the first 9.5 hours after surgery in group 1 was 16.9 ± 11.9 mg versus 31.1 ± 18.0 mg in group 2 (P < .05). Postoperative nausea and vomiting occurred with equal frequency (87%) in both study groups, and there was no difference between groups in time to achieve fitness for discharge, i.e., a postanesthesia discharge score of ≥9. Conclusion. Preoperative tumescent infiltration with lidocaine results in reduced pain and lower postoperative opioid requirements in the initial hours after reduction mammoplasty.     

肿胀麻醉技术在假体置入隆乳术中的应用

目的：探讨肿胀麻醉方法在隆乳术中的应用效果。方法：用2%的利多卡因10ml,1%肾上腺素1ml,5%碳酸氢钠10ml,地塞米松5mg配成500ml的肿胀液,在肿胀麻醉下对158例受术者实施假体置入隆乳术。结果：158例受术者均能在肿胀麻醉下耐受手术,仅少数患者有轻微疼痛,配合肋间神经阻滞,效果非常满意。结论：肿胀麻醉法隆乳术安全、可靠、方法简单、效果满意,节约费用,手术时间短,适用于各种术式的隆乳术。     

吸脂术中大剂量使用利多卡因的血药浓度监测及意义

目的探讨作为局部麻醉剂的利多卡因在肿胀法脂肪抽吸术中的极限剂量是多少,既能达到良好的镇痛效果,又能安全地使用而不产生毒副作用。方法对14例大剂量使用低浓度利多卡因作为局麻药的脂肪抽吸术的术中和术后血清利多卡因浓度以免疫荧光测定法进行了动态监测,作出其时间-浓度曲线,并与临床表现相对照。结果在此类手术中,利多卡因在0.1mg/ml的浓度下,加入1/1百万～1/2百万肾上腺素,其用量可达35mg/kg 体重而血清高峰浓度仍在安全范围内,无中毒症状,既可减轻病人的疼痛,又可减少出血,提高安全性,增加脂肪抽吸量。结论本研究为肿胀法吸脂术中大剂量使用利多卡因的临床实践提供了理论依据。