Continuous thoracic epidural anesthesia with 0.2% ropivacaine versus general anesthesia for perioperative management of modified radical mastectomy

We evaluated in this prospective study the effectiveness of continuous thoracic epidural anesthesia (TEA) and postoperative analgesia with ropivacaine and compared it with general anesthesia (GA) and opioids for pain relief, side effects, postanesthesia recovery, and hospital discharge after modified radical mastectomy. Sixty ASA physical status II and III patients undergoing mastectomy were randomly assigned to two study groups of 30 patients each. In the TEA group, an epidural catheter was inserted at T6-7, and 5--10 mL of 0.2% ropivacaine was injected to maintain anesthesia and to continuously administer adequate analgesia for 48 h. GA was induced with IV 1--2 mg of midazolam or 50--100 microg/mL of fentanyl followed by 50--150 mg of propofol and was maintained with sevoflurane and 50% N(2)O in oxygen. The Aldrete score system was used to evaluate postanesthesia recovery, a verbal rating scale was used for assessment of pain intensity, and a postanesthesia discharge scoring system was used for discharge home. The demographic data and side effects (except for nausea and vomiting) (GA 43%, TEA 10%, P = 0.0074) and discharge home were similar in both groups. However, the number of patients ready for discharge from the recovery room during the first postanesthesia hour (Aldrete score of 10) was significantly larger after TEA (80%) than after GA (33%) (P = 0.0006). GA patients experienced significantly more (P < 0.001) substantial pain than TEA patients on Day 0 (70%), Day 1 (53%), and Day 2 (27%) after the surgery. Patient satisfaction was greater with TEA (70%) than with GA (30%) (P < 0.001). We conclude that TEA with ropivacaine provides better postoperative pain relief and less nausea and vomiting, facilitates postanesthesia recovery, and gives greater patient satisfaction than GA.

Epidural blood patch after thoracotomy for treatment of headache caused by surgical tear of dura

IMPLICATIONS

During a right lobectomy operation, a patient with carcinoma of the lung developed postoperative headache caused by a leak of cerebrospinal fluid from an area of dura injured during the procedure. Conservative treatment was unsuccessful. Injection of 10 mL of the patient's own blood into the epidural space relieved the headache.

Chronic relapsing pancreatitis from a scorpion sting in Trinidad

Chronic relapsing pancreatitis is a rare cause of abdominal pain in children and exceptionally rarely is related to a scorpion sting. We describe a 13-year-old girl who, following envenoming by a scorpion, developed recurrent attacks of sharp, intermittent pain in the umbilical region associated with fever, nausea, anorexia and vomiting, and changes in her psychological behaviour. Thorough clinical evaluation, including CT scanning, disclosed unabated pancreatitis. A modified Puestow procedure was performed with very good results. Physicians should be aware that in chronic relapsing pancreatitis, particularly in children, a scorpion sting should be considered an aetiological possibility.

Surgical management of pediatric renal trauma: an urban experience

This study was undertaken to review our operative experience in the management of pediatric renal trauma. Over a 2-year period (August 1988 to August 1990) 25 of 60 children undergoing celiotomy sustained renal injuries. There were 22 boys and three girls ranging in age from 5 to 18 years. Eighty-four per cent were victims of gunshot wounds, 12 per cent were stabbed, and 4 per cent sustained blunt trauma. The 25 injured children sustained a total of 45 individual organ injuries. Only 16 per cent required a nephrectomy, while the great majority (84%) were managed with renal sparing procedures. When we compared survivors to nonsurvivors, there was more thoracic and vascular injury along with more blood transfusion requirements in nonsurvivors. There was no statistical difference in Pediatric Trauma Score (PTS) between survivors and nonsurvivors (9.8 +/- 0.26 vs 9.5 +/- 1.5). Preoperative intravenous pyelographies (IVPs) performed in 52 per cent of all patients demonstrated the site of injury, presence of contralateral function as well as the anatomic position of the kidneys. We conclude that renal injury is common following penetrating abdominal trauma in childhood, however, these injuries can be managed by early operation with renal sparing procedures. There is a high incidence of associated intra-abdominal injury in those who have sustained penetrating renal trauma, but mortality is more common in patients sustaining associated thoracic and vascular injuries. An IVP should be performed, even in the absence of hematuria, when trauma trajectory strongly suggests urologic injury. This study also illustrates the sharp rise in drug-related urban violence with an associated increase in pediatric renal trauma.

Incompatibility of Isovue 370 and papaverine in peripheral arteriography

Complete thrombotic occlusion of the arterial blood flow in the upper extremity was produced after mixture of Isovue 370 (iopamidol) and papaverine hydrochloride during routine angiography. Bolus and then continuous infusion of urokinase failed to dissolve the thrombus. The patient required a surgical thrombectomy and recovered uneventfully. This case report demonstrates that caution should be exercised when Isovue 370 and papaverine are used in angiography.

Clinical assessment of gestational age: a comparison of two methods

The ratio of fundal height (FH) to maternal abdominal length (MAL) was defined as percentage of maternal abdominal length (PMAL) and compared to FH alone in 100 consecutive uncomplicated pregnancies from the 18th week of gestation to delivery at term. Reference graphs for fetal growth evaluation were developed using these two clinical methods. The predictive value of each technique was assessed by comparing gestational age estimates in 29 additional patients at various gestational ages. The correlation coefficient between the known gestational ages and estimates by the PMAL method was .86, and between known gestational ages and estimates by the FH method, .94. Twenty more patients were evaluated by three obstetricians in a double-blind fashion to determine gestational ages by each technique. The average deviation from the real gestational age varied from 2.07 to 3.14 weeks using the FH method, and from 2.82 to 3.97 weeks using the PMAL graph. It was concluded that FH measurement correlates better with gestational age than its ratio to the MAL.

A rare malposition of the central venous catheter

The left pericardiacophrenic vein was accidentally cannulated during an attempt to establish central venous catheterization through the left internal jugular vein. Chest roentgenograms and intravenous contrast material confirmed the position of the catheter. Although our patient developed no problems during a five-day cannulation, based on published information, it is advisable to reposition the catheter to avoid perforation of the pericardiacophrenic vein and possible cardiac tamponade.

Endovaginal sonography for the early diagnosis of intrauterine and ectopic pregnancies

Endovaginal sonography, together with beta-HCG titre, was used to diagnose ectopic pregnancy in 58 patients. Transabdominal ultrasound failed to conclude this diagnosis. The data from endovaginal sonography revealed the presence of a gestational sac in all 15 patients with normal pregnancies at a beta-HCG level of 1042 mIU/ml. Of the 23 patients with pathological pregnancies only 61% had an intrauterine gestational sac. Only 15% of the 20 patients with ectopic pregnancies showed an increase in beta-HCG greater than 66% in 48 h, while in normal pregnancy, this increase was found in 71% of the patients. The endovaginal findings of the ectopic gestation revealed a complex adnexal mass in 55%, a cystic mass in 30% and fluid in the cul-de-sac in 20%. The diagnostic indices of adnexal and cul-de-sac sonographic findings in the ectopic group further improved specificity and positive predictive accuracy. The detection of ectopic versus intrauterine gestation showed a high sensitivity of 95%, a specificity of 100%, a positive predictability of 100% and a negative predictability of 97%. The data confirm the value and reliability of endovaginal and cul-de-sac sonography, combined with measurement of the beta-HCG level in the early diagnosis of ectopic pregnancy. This combined approach not only makes the differentiation between normal and extrauterine gestation more accurate but also helps to avoid unnecessary diagnostic laparoscopy and hospitalization.

Effects of verapamil on indirect muscle twitch responses

The effects on indirectly elicited muscle twitch amplitude associated with the calcium (slow) channel blocker, verapamil, with or without pancuronium were investigated using isolated bullfrog sciatic nerve-sartorius muscle preparations. Verapamil (2-8 mM) produced a dose-related depression of indirect muscle twitch height (P less than 0.05). Twitch response was depressed 11% below control by the lowest concentration employed and 86% by the highest concentration. Pancuronium (0.07 mM) depressed neuromuscular function 35% below control (P less than 0.05). The combination of 5 mM or 8 mM verapamil with 0.07 mM pancuronium caused significantly greater degrees of depression than either drug alone. Verapamil produced significant depression of twitch height in vitro in relatively high concentrations. The mechanism of action remains unknown. Verapamil possesses pharmacologic properties that may be unrelated to slow (calcium) channel inhibition. The reduction of muscle twitch height caused by verapamil alone (5 mM) could not be antagonized by neostigmine, calcium, or frequent washings.

Neuromuscular blocking action of verapamil in cats

The effects of the calcium (slow) channel blocker verapamil, on non-cardiac excitable membranes were examined in vivo. In barbiturate anaesthetized cats, the effect of intravenously administered verapamil (0.1, 0.2, and 0.4 mg.kg-1) on isometric twitch amplitude of the flexor carpi radialis muscle, elicited by indirect and direct electrical stimulation, was determined. At all doses tested, verapamil significantly reduced muscle twitch amplitude from control values. The effect of dosage on twitch reduction was far more pronounced for indirect than direct stimulation. Full recovery to control was observed by 90 minutes only with the lowest dose (0.1 mg.kg-1 IV). Reduction of twitch amplitude (direct and indirect) lasted the duration of the experiment (180 minutes) for the two higher doses of verapamil. No significant changes in blood pressure, cardiac rate or rhythm were observed. The specific site and mechanism of verapamil's neuromuscular blocking action remains unclear. In clinical situations where potent inhalation agents, adjuncts or neuromuscular blocking agents may be used, therapeutic doses of verapamil may interact to promote muscle weakness.

Neuromuscular and electrocardiographic responses to verapamil in dogs

Because severe muscular weakness was noted in animals receiving verapamil in doses exceeding those used in humans, we studied the effects of verapamil on neuromuscular function and its correlation with myocardial conduction. The flexor carpi radialis and its nerves were surgically exposed in mechanically ventilated dogs during pentobarbital anesthesia. Indirect and direct electrical stimulation was applied and twitch height recorded following the intravenous administration of verapamil. Twenty animals received one of four dose schedules. The results showed a significant dose-related depression of twitch height to indirect stimulation. Twitch height to direct stimulation was reduced only with the highest dose. The onset of depression of indirect stimulation was temporally associated with onset of A-V conduction delay. However, recovery following indirect stimulation lagged behind recovery of the ECG by 30 min. Recovery times of twitch height following indirect stimulation ranged from 60-208 min and also were dose-related. The qualitative similarity of pancuronium and verapamil on indirect twitch height suggests a similar site of action, i.e., the neuromuscular junction. A presynaptic or postsynaptic effect of verapamil could not be discerned in this study. Verapamil may produce an unrecognized source of weakness in the anesthetized patient either alone or through interaction with anesthetic agents or adjuncts.

Reversal of procaine conduction blockade by adenine nucleotides in vivo and in vitro

The effect of the adenine nucleotides on procaine-induced conduction block in rats was investigated in vivo and in vitro. Both adenine and cyclic nucleotides significantly shortened the duration of sciatic nerve blocks in rats without affecting the frequency, degree of block or time of onset. Adenosine 5'-triphosphate (ATP) and N6, O2' dibutyryl 3':5'-monophosphate (db-cyclic AMP) were most effective. In isolated sciatic nerve preparations, the adenine nucleotides (ATP, adenosine 5'diphosphate (ADP), adenosine 5'monophosphate (AMP)) rapidly reversed procaine-induced depression of the action potential. These results suggest that local anesthetic effects may be mediated through interference with the physiological functions of the nucleotides.