Haematoma block: Assessment of postoperative analgesic effect following manipulation of distal forearm fractures

Haematoma block has been shown to provide a safe and effective method of analgesia for the manipulation of wrist fractures in adults,¹ but has previously been little used in paediatric anaesthetic practice. There is little published data on the use of this technique for postoperative analgesia.The aim of this study was to assess the efficacy of haematoma block in providing postoperative analgesia in children following manipulation of distal forearm fractures. Forty healthy children with fractures of the distal radius and ulna were randomised to one of two groups. Against the background of a standard general anaesthetic, the patients were randomly allocated to receive either 1 ml of normal saline per 10 kg body weight or 1 ml of 0.25% bupivacaine per 10 kg of body weight injected into the fracture site under general anaesthesia prior to manipulation of the fracture. Clinical staff were unaware as to the nature of the injected solution. The two groups were compared in terms of postoperative analgesic requirements, the time to first analgesia, and in terms of half hourly pain and sedation scores.The children in the bupivacaine group had significantly lower pain scores throughout the whole study period. The median pain scores for the bupivacaine group were significantly better at 30, 60 and 90 minutes. The median time to first analgesia was 120 minutes for the bupivacaine group and 90 minutes for the saline group.This study shows that intraoperative haematoma block with 0.25% bupivacaine improves pain scores in the early postoperative period and prolongs the time to first analgesia.     

A comparative study of intravenous diazepam and midazolam for oral surgery

Intravenous diazepam was compared with intravenous midazolam for conscious sedation in a single-blind study of 50 Hong Kong Chinese patients acting as their own controls. Verrill's sign was used as the end-point of sedation, and bilateral, similarly impacted lower third molars served as the surgical model. The drugs produced comparable levels of sedation, stable vital signs, and good operating conditions in all patients. Midazolam had numerous advantages over diazepam: more rapid onset of sedation, less pain during injection, profound anterograde amnesia, and fewer postoperative complications. The incidence of thrombophlebitis was low with both drugs and appears to be so in Chinese in general. A significant majority of the patients preferred sedation to other techniques and midazolam to diazepam.     

Pulmonary edema in the neuroradiology suite: a diagnostic dilemma

PURPOSE: To present the case of an initially unexplained complication of sudden pulmonary edema in a patient during stenting of the carotid artery in the interventional neurology suite. CLINICAL FEATURES: A 46-yr-old woman (ASA III) having an intracavernous carotid artery angioplasty and stenting procedure under neurolept anesthesia developed sudden pulmonary edema on completion of an otherwise uneventful stenting procedure. The patient responded well to initial management of pulmonary edema although the cause of the edema remained unclear. On retrospective examination of data and with the evolution of clinical signs it became apparent that the patient had suffered a subarachnoid hemorrhage which eventually resulted in her death. CONCLUSIONS: Clinical signs of intracerebral events may be slow to evolve. The cause of sudden pulmonary edema in patients undergoing an interventional neuroendovascular procedure is likely to be neurogenic in origin despite the initial lack of neurological signs.     

Primary congenital pulmonary hypoplasia—genetic component to aetiology

Primary congenital pulmonary hypoplasia, defined as congenital pulmonary hypoplasia occurring in the absence of other congenital anomalies, is an exceedingly rare condition of unknown aetiology. We report on two cases that presented as severe progressive respiratory failure immediately after birth in siblings of a consanguinous marriage, and we postulate that a genetic aetiology may be responsible for the arrest of lung maturation in utero . The possibility of a genetic component to the aetiology has not been previously documented in the literature.     

Acute Lung Injury after Instillation of Human Breast Milk or Infant Formula into Rabbits' Lungs

Background: Recent interest in shortening the fasting interval after ingestion of milk products demonstrated large volumes of breast milk in the stomach 2 h after breastfeeding. Although aspiration is a rare event, if it were to occur with human breast milk, it is important to understand the extent of the lung injury that might occur. Therefore, the response to instillation of acidified breast milk and infant formula in the lungs of adult rabbits was studied.

Methods: In 18 anesthetized adult rabbits, 1 of 3 fluids (in a volume of 0.8 ml *symbol* kg sup -1 and pH level of 1.8, acidified with hydrochloric acid); saline, breast milk, or infant formula (SMA, Wyeth, Windsor, Ontario), was instilled into the lungs via a tracheotomy. The lungs were ventilated for 4 h after instillation. Alveolar-to-arterial oxygen gradient and dynamic compliance were measured before and at hourly intervals after instillation. After 4 h, the rabbits were killed and the lungs were excised. Neutrophil infiltration was quantitated by a pathologist blinded to the instilled fluid. A histologic control group of four rabbits was ventilated under study conditions without any intratracheal fluid instillation.

Results: Alveolar-to-arterial oxygen gradient increased and dynamic compliance decreased significantly during the 4 h after instillation of both breast milk and infant formula compared with baseline measurements and with saline controls (P < 0.05). The neutrophil counts in the lungs from the saline, breast milk, and formula rabbits were significantly greater than those in the control group.     

Sterilization of Women with Eisenmenger Syndrome: Report of 4 Cases

Summary: Maternal mortality exceeding 50% and perinatal loss of more than 45% contraindicate pregnancy in females with Eisenmenger syndrome. Sterilization is the contraceptive method of choice. Any operation carries a very significant risk in persons with Eisenmenger syndrome; the anaesthetic mortality has been reported to be 19%. This paper details the successful sterilization of 4 women with Eisenmenger syndrome at our institution.     

Critical incidents in paediatric anaesthesia: an audit of 10 000 anaesthetics in Singapore

BACKGROUND: We undertook an audit of paediatric perioperative incidents in the first 10000 anaesthetics administered in KK Women's and Children's Hospital in Singapore between May 1997 and April 1999. The spectrum of surgery performed ranged from simple ambulatory surgery to open heart surgery for complicated congenital heart diseases. METHODS: An audit form is completed for every anaesthetic delivered and critical incidents are reported on the reverse blank page of the audit form. An anaesthetic incident was defined as 'any incident which affected, or could have affected, the safety of the patient under anaesthetic care'. RESULTS: Two hundred and ninety-seven critical incidents were reported. The majority of them happened in healthy patients (80.1% ASA I and II) scheduled for elective surgery (73.3%). Critical incidents in infants less than 1 year of age were four times as common as in older children (8.6% versus 2.1%). Incidents occurred mainly during maintenance (80.6%). There was no anaesthetic mortality. Respiratory events were the most common (77.4%) with laryngospasm accounting for 35.7%. Cardiovascular incidents (10.8%) included hypotension from haemorrhage and sepsis, and dysrhythmias. The incidence of equipment and pharmacologically related problems was low. CONCLUSIONS: Future reviews of a larger patient population may be helpful to determine trends of perioperative events and whether quality assurance programs have made a difference.