Intensive care patients in district hospitals. A case for transfer?

Patients, admitted and primarily treated in a rural hospital, who required varying periods of intensive care management have been reviewed. The criteria for transfer of such patients to more specialised units and the hazards associated with ambulance travel are discussed. We describe measures to reduce these hazards and also a scheme for more uniform documentation and follow-up of such cases by the anaesthetist involved in primary care.     

Intraoperative hyperthermia in a paediatric patient with cystinosis

Cystinosis is a rare autosomal recessive inherited disorder of amino acid metabolism. Little is known of the affects of general anaesthesia on the disease (Tobias 1993) and complications relating to anaesthesia have not been previously reported. Infantile cystinosis presents as progressive renal failure and the Fanconi syndrome and metabolic bone disease often develop. We describe the case of a child who presented with signs of apparent malignant hyperthermia (MH) under general anaesthesia and was treated with dantrolene. During a repeat ‘trigger-free’ general anaesthetic he developed a fever which responded to paracetamol. The metabolic effects of cystinosis and its similarity to MH will be discussed.     

Halothane and Isoflurane Decrease the Open State Probability of Potassium sup + Channels in Dog Cerebral Arterial Muscle Cells

Background: Both halothane and isoflurane evoke cerebral vasodilation. One of the potential mechanisms for arterial vasodilation is enhanced Potassium sup + efflux resulting from an increased opening frequency of membrane Potassium sup + channels. The current study was designed to determine the effects of volatile anesthetics on Potassium sup + channel current in single vascular smooth muscle cells isolated from dog cerebral arteries.

Methods: Patch clamp recording techniques were used to investigate the effects of volatile anesthetics on macroscopic and microscopic Potassium sup + channel currents.

Results: In the whole-cell patch-clamp mode, in cells dialyzed with pipette solution containing 2.5 mM EGTA and 1.8 mM CaCl2, depolarizing pulses from 60 to +60 mV elicited an outward Potassium sup + current that was blocked 65 plus/minus 5% by 3 mM tetraethylammonium (TEA). Halothane (0.4 and 0.9 mM) depressed the amplitude of this current by 18 plus/minus 4% and 34 plus/minus 6%, respectively. When 10 mM EGTA was used in the pipette solution to strongly buffer intracellular free Calcium2+, an outward Potassium sup + current insensitive to 3 mM TEA was elicited. This Potassium sup + current, which was reduced 51 plus/minus 4% by 1 mM 4-aminopyridine, was also depressed by 17 plus/minus 5 and 29 plus/minus 7% with application of 0.4 and 0.9 mM halothane, respectively. In cell-attached patches using 145 mM KCl in the pipette solution and 5.2 mM KCl in the bath, the unitary conductance of the predominant channel type detected was 99 pS. External application of TEA (0.1 to 3 mM) reduced the unitary current amplitude of the 99 pS Potassium sup + channel in a concentration-dependent manner. The open state probability of this 99 pS Potassium sup + channel was increased by 1 micro Meter Calcium2+ ionophore (A23187). These findings indicate that the 99 pS channel measured in cell-attached patches was a TEA-sensitive, Calcium2+ -activated Potassium sup + channel. Halothane and isoflurane reversibly decreased the open state probability (NPo), mean open time, and frequency of opening of this 99 pS Potassium sup + channel without affecting single channel amplitude or the slope of the current-voltage relationship.     

Postincisional local anaesthetic infiltration of the rectus muscle decreases early pain and morphine consumption after abdominal hysterectomy

We conducted a randomized, double-blind study to evaluate the degree to which selective infiltration of the rectus muscle may influence pain and morphine requirements after major intra-abdominal surgery 6 h postoperatively. One hundred Chinese patients presenting for elective total abdominal hysterectomy received a standard general anaesthetic and were randomly divided into two groups to receive intramuscular injection of 0.4 ml kg⁻¹ of either bupivacaine 0.5 or 0.9% saline (maximum to 20 ml) to the rectus muscle wound at the end of surgery. The mean hourly pain (visual analogue score (VAS)) was statistically significant at 0–2 and 4 h while mean hourly morphine consumption was statistically significant at 1, 2 and 4 h postoperatively between the two groups (P<0.05). Total morphine consumption at 6 h postoperative was significantly reduced from 21.7 mg (mean) and 20 mg (median) in the saline group to 12.8 mg (mean) and 12 mg (median) in the bupivacaine group respectively (P<0.05). These results indicate that the rectus muscle is an important origin, and injury and spasm of this muscle potential mechanisms, of pain in the early postoperative period after abdominal hysterectomy.     

Lumbar Sympathetic Chain Neuromodulation with Implanted Electrodes for Long‐Term Pain Relief in Loin Pain Haematuria Syndrome

Introduction. Loin pain‐hematuria syndrome (LPHS) is a rare clinical entity causing unilateral or bilateral intractable flank and loin pain with hematuria. The etiology is poorly understood, and the diagnosis is made by exclusion of urological and nephrological conditions. The management is mainly symptomatic aiming for pain relief with nonopioid and opioids analgesics, and interventions such as capsaicin infusion into the renal pelvis, percutaneous regional nerve blocks, and laparoscopic or open surgical procedures, none of them providing lasting pain relief. Methods. We describe four cases of LPHS in which long‐term pain relief was achieved successfully by neuromodulation of lumbar sympathetic plexus with implanted electrodes. All patients underwent an initial successful trial of neuromodulation with Stimulong monoelectrode (Pajunk, GmbH, Geisingen, Germany) inserted percutaneously to lie adjacent to L3–L4 vertebral bodies followed by permanent implantation of the stimulation system using four contact electrodes (Medtronic Inc, Minneapolis, Minnesota, USA) in two patients with excellent long‐term pain relief. Results. All our patients had significant reductions in visual analog scale scores and analgesic consumption for the duration of the monoelectrode trial and in one patient beyond six months. Of the two patients who had full implants, pain relief is excellent with minimal analgesic consumption and one has resumed employment. There were no complications. Discussion. LPHS is very difficult to treat with some experts maintaining it is mainly psychological. Conservative treatments are often unsatisfactory and radical measures not reliable. Peripheral stimulation of nerves and plexuses has been successful as shown from case reports. All our patients preferred low‐frequency stimulation although its precise mode of action is uncertain. Conclusion. Our experience shows that lumbar sympathetic chain neuromodulation in intractable LPHS not amenable to conservative therapy is a reasonable alternative before radical interventions. More experience is needed in multiple centers before its recommendation for refractory LPHS.