Continuous spinal anaesthesia

CD59 is a cell membrane-bound complement regulatory protein on glomerular cells that inhibits C5b-9 assembly and insertion. This report describes a recently developed model of immune thrombotic microangiopathy (TMA) induced by the renal artery perfusion of anti-glomerular endothelial cell (anti-GEN) antibody. To examine the role of CD59 in protecting the GEN from immune-mediated injury, rats underwent selective renal artery perfusion with F(ab')2 fragments of anti-CD59 monoclonal antibody to block CD59 activity or control mouse IgG followed by anti-GEN antibody or control goat IgG. Neutralization of CD59 in normal rats did not result in any significant functional or histologic changes. Perfusion with anti-CD59 did not change deposition of the pathogenic anti-GEN IgG used to induce the TMA model. However, neutralization of CD59 in the TMA model resulted in more C5b-9 formation in glomeruli, accompanied by increased platelet and fibrin deposition, more severe endothelial injury, and reduced renal function compared with the animals perfused with control F(ab')2 fragments. These results demonstrate directly that CD59 serves a protective role for GEN in this TMA model of rats, and confirm that C5b-9 formation has a critical pathogenic role in the mediation of the disease. CD59 may play an important role in protecting glomerular endothelium from other complement-mediated types of injury.     

Epidural anaesthesia and spinal haematoma

PURPOSE: Haematoma formation in the spinal canal due to epidural anaesthesia is a very rare but serious complication. This paper presents a comprehensive review of case reports. SOURCE: Sampling of case reports over a 10 yr period, medline-research (1966-1995) and cross-check with former reviews. FINDINGS: Fifty-one confirmed spinal haematomas associated with epidural anaesthesia were found. Most were related to the insertion of a catheter, a procedure that was graded as difficult or traumatic in 21 patients. Other risk factors were: fibrinolytic therapy (n = 2), previously unknown spinal pathology (n = 2), low molecular weight heparin (n = 2), aspirin or other NSAID (n = 3), epidural catheter inserted during general anaesthesia (n = 3), thrombocytopenia (n = 5), ankylosing spondylitis (n = 5), preexisting coagulopathy (n = 14), and intravenous heparin therapy (n = 18). CONCLUSION: Coagulopathies or anticoagulant therapy (e.g., full heparinization) were the predominant risk factors, where-as low-dose heparin thromboprophylaxis or NSAID treatment was rarely associated with spinal bleeding complications. Ankylosing spondylitis was identified as a new, previously unreported risk factor. Analysis of reported clinical practice suggests an incidence of haematoma of 1:190,000 epidurals.     

Pituitary apoplexy after spinal anaesthesia

We report the case of a previously healthy 51-yr-old male who underwent an uneventful total hip replacement under spinal anaesthesia. His immediate postoperative course was complicated by the development of a severe frontal headache. Initial conservative treatment included oral analgesics and an epidural blood patch. The headache persisted and was followed by progressive vision loss and a right partial third nerve palsy. The patient was almost blind at the time of transfer to our neurosurgical unit. Relevant investigations revealed marked hyponatraemia (serum sodium concentration 122 mmol litre-1) and second-degree heart block (Mobitz I). A CT scan showed a pituitary tumour and confirmed the clinical diagnosis of pituitary apoplexy. Urgent craniotomy was scheduled and a large necrotic pituitary adenoma was excised. The postoperative course was uneventful with return of near normal vision at the time of discharge. Clinicians should consider this diagnosis when focal neurological deficits occur with post-dural puncture headache.     

Integrating self-help into psychotherapy: 16 practical suggestions.

Psychologists routinely recommend self-help to their patients but desire guidance on the optimal methods and resources for doing so. This article provides 16 suggestions, culled from both the research literature and clinical experience, for integrating self-help into psychotherapy. Among the clinical recommendations are broadening the definition of self-help, assessing clients' self-help histories, offering tangible support in linking clients with self-help, tailoring the self-help resource to the person (not only the disorder), assisting clients with the administration of difficult self-help programs, using self-help during waiting and maintenance stages, and addressing clients' reservations about its use. Psychologists' top-rated self-help books, autobiographies, and films are presented. By their behavior, psychologists can enhance the effectiveness of self-help within the context of psychotherapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Unilateral spinal anaesthesia with hyperbaric bupivacaine

BACKGROUND: The dosage of local anaesthetic and the time the patient must be kept in the lateral decubitus position for a unilateral spinal anaesthesia is not known. The aim of this study was to determine the ideal dosage of hyperbaric bupivacaine and the time required for the lateral decubitus position for a unilateral spinal block. METHODS: Ninety patients who were scheduled to receive spinal block for surgery in the lower extremity were randomised into 9 groups (n = 10). The spinal block was performed through the L4-L5 intervertebral space with the patient in the lateral decubitus position. Patients in groups Ia, Ib, Ic; IIa, IIb, IIc; IIIa, IIIb, IIIc received 1.5 ml of 0.5%, 2 ml of 0.5%, and 2.5 ml of 0.5% hyperbaric bupivacaine solutions, respectively. The patients were turned to the supine position for 5 min after the injection in groups Ia, IIa, IIIa, 10 min after the injection in groups Ib, IIb, IIIb, and 15 min after the injection in groups Ic, IIc, IIIc. The onset and regression of sensory and motor block were checked and compared between the dependent and non-dependent sides in each group. RESULTS: The rate of block progression of the non-dependent side was higher in the groups receiving 2.5 ml 0.5% hyperbaric bupivacaine solution than in the other groups; at the same time the level of block was higher and the duration of block was longer. The incidence of hypotension was 10-20% in these groups. In the 2 ml 0.5% hyperbaric bupivacaine solution groups, a satisfactory block level and duration of anaesthesia for surgery was obtained. The rate of block progression to non-dependent side in the groups receiving 1.5 ml of 0.5% hyperbaric bupivacaine solution was lower than the other groups, but the duration of block was shorter and the level of block was lower than the other groups. CONCLUSION: For unilateral spinal anaesthesia in lower extremity operations, 2ml 0.5% hyperbaric bupivacaine solution for operations above the knee and 1.5 ml 0.5% hyperbaric bupivacaine solution for operations below the knee and keeping the patients for 10 min in the lateral decubitus position were found to be appropriate.     

Granisetron prevents nausea and vomiting during spinal anaesthesia for caesarean section

Acute pancreatitis is accompanied by destruction and digestion of tissues, causing hypercytokinemia and hyperreactivity of leukocytes (macrophages and neutrophils) and vascular endothelial cells. As one of the biological defense mechanisms in this condition, neutrophils infiltrate vital organs such as the lung, liver, and digestive organs. When acute pancreatitis is complicated by infection, hyperreactive macrophages release a large amount of proinflammatory cytokines that activate primed neutrophils, as a "second attack." Utilizing proteolytic enzymes and oxidant, neutrophils injure the infiltrated vital organs, causing cellular damage and dysfunction of vital organs distant from the pancreas. Multiple organ failure in acute pancreatitis with septic complications can develop, at least in part, by proinflammatory cytokine release and neutrophil activation.     

Spread of spinal anaesthesia for caesarean section in singleton and twin pregnancies

We have compared the spread of spinal anaesthesia in parturients with singleton and those with twin pregnancies. Fifty-five unpremedicated patients with uncomplicated pregnancy scheduled for Caesarean section were allocated to two groups: group I = 35 singleton mothers; group II = 20 with twin pregnancy. Both groups received spinal anaesthesia with hyperbaric bupivacaine 10 mg (2 ml of 0.5%). Mean birthweight was 3290 (SD 452) g and 5008 (495) g in groups I and II (combined birthweights), respectively. We found a statistically significant difference in onset and maximal cephalad spread of spinal anaesthesia (group I median T5, range T8-T4; group II T3, range T6-T2). The mechanisms of higher cephalad spread of spinal anaesthesia in parturients may be a decrease in cerebrospinal fluid volume secondary to shunting of blood from the obstructed inferior vena cava to the extradural venous plexus and increased nerve sensitivity to local anaesthetics because of increased concentrations of progesterone. The twin pregnancy group had heavier, larger uteri and greater daily production of progesterone.     

Maternal and uteroplacental haemodynamic state in pre-eclamptic patients during spinal anaesthesia for Caesarean section

We have studied the effects of crystalloid (Ringer's acetate 1 litre) preloading and subsequent spinal anaesthesia in 12 pre-eclamptic parturient patients undergoing elective Caesarean section. Maternal placental uterine artery circulation was measured using a pulsed colour Doppler technique with simultaneous measurement of maternal haemodynamic state. Despite preloading, mean maternal systolic arterial pressure (SAP) decreased significantly and marked maternal hypotension (SAP < 80% of baseline value) was recorded in two patients after induction of spinal anaesthesia. Mean central venous pressure increased significantly after preload, but decreased to baseline shortly after induction of spinal anaesthesia. Mean pulsatility index (PI) in the uterine artery did not change during preload or spinal block. In one patient, uterine artery PI increased significantly when SAP decreased to 71% of the baseline value, 14 min after induction of spinal anaesthesia. These results suggest that preload with crystalloid solution does not prevent maternal hypotension in pre-eclamptic patients, and that changes in uterine artery velocity waveforms were minor when SAP was 80% or more of baseline during spinal anaesthesia. These changes did not appear to have any major effect on the clinical condition of the neonate, as assessed by Apgar score and umbilical artery pH values.     

Apnea following spinal anaesthesia in two former pre-term infants

Telomerase activity is associated with the proliferative activity of cells. In the endometrium, telomerase activity is higher in the proliferative phase than in the secretory phase of the menstrual cycle, suggesting that telomerase activity may occur primarily in the glandular epithelial cells. To test this, a dissociated cell culture of the endometrium was performed, and the telomerase activity in each cell fraction was analysed. Telomerase activity was found in all 10 endometrial tissues of the proliferative phase of the menstrual cycle. Both the fragments of epithelial glands and single cells, which were prepared by enzymatic dissociation, showed telomerase activity. In the 7 day cell culture, it was found in nine out of 10 epithelial cell enriched fractions, but in none of the stromal cell enriched fractions. Flow cytometric analysis showed that the epithelial enriched fraction was contaminated with a predominant number of stromal cells, while the stromal cell enriched fraction was comprised mostly of stromal cells with apparent proliferative activity. Our results suggest that telomerase activity of the endometrium occurs primarily in the epithelial cells in the endometrium and that the stromal cells do not express telomerase activity regardless of their potent proliferative activity.     

Safety and efficacy of spinal vs general anaesthesia in bone marrow harvesting

In cases of completed middle cerebral artery territory stroke, prognosis is very poor and the clinical course is characterised by a rapid decline in consciousness and signs of herniation 2-4 days after the onset of symptoms due to a space-occupying mass. Failure of conservative therapy is the rule, and herniation is the usual cause of death, occurring in almost 80 per cent of cases. Recently published results have suggested that hemicraniectomy may improve survival in patients with massive hemisphericstroke, decreasing mortality to less than 35 per cent. The article presents what is probably the first case to be reported in Sweden, where hemicraniectomy was performed on a 45-year-old woman with right hemispheric completed middle cerebral artery infarction.     

Power spectral analysis of heart rate variability after spinal anaesthesia

The relationships among coping styles and psychopathology were examined with the MMPI-2 content scales and a reliable and valid coping measure--the Coping Inventory For Stressful Situations (CISS). Subjects were 167 higher-functioning normal adult males. The results are consistent with previous research that employed the CISS; a strong positive association was found between emotion-oriented coping strategies and various measures of psychopathology. Task-oriented coping strategies were found to be unrelated to these measures. Results are discussed in the context of a potential model for understanding the various relationships among coping styles and psychopathology.     

Flexible outpatient hysteroscopy without anaesthesia: a safe, successful and well tolerated procedure

The objective of this study was to assess the feasibility and tolerance of diagnostic outpatient flexible hysteroscopy without anaesthesia. Records from 554 consecutive patients were analysed retrospectively. Success rate, reasons for failure, adverse reactions and level of pain were the main outcome measures. Hysteroscopy was successful in 90.5% of patients and well tolerated in 93.3%; 5.4% experienced moderate to severe pain. Inability to negotiate the cervical canal accounted for 47% of failed procedures and poor view for 42%. These results suggest that flexible outpatient hysteroscopy without anaesthesia is a successful and well tolerated procedure.     

Prevention of hypotension during spinal anaesthesia for caesarean section: ephedrine infusion versus fluid preload

We compared the efficacy of prophylactic ephedrine infusion over fluid preloading in prevention of maternal hypotension during spinal anaesthesia for Caesarean section. Forty-six women undergoing elective Caesarean section at term were allocated randomly to receive either intravenous fluid preloading with Hartmann's solution 20 ml.kg-1 (fluid group) or prophylactic intravenous ephedrine 0.25 mg.kg-1 (ephedrine group). Moderate hypotension was defined as > or = 20% reduction in systolic blood pressure and severe hypotension as > or = 30% reduction in systolic blood pressure. Maternal uterine circulation was measured using Doppler ultrasound in 11 parturients before and after spinal anaesthesia. There was a lower incidence of severe hypotension in the ephedrine group compared with the fluid group (35% vs. 65%, p = 0.04), although the incidence of moderate hypotension was similar. Mean umbilical venous pH was higher in the ephedrine group than in the fluid group (7.33 vs. 7.29, p = 0.02) and the number of patients shivering was lower in the ephedrine group (2 vs. 9, p = 0.02). No difference was found between pre- and postspinal uterine artery pulsatility indices in either group. We conclude that prophylactic ephedrine infusion alone is at least as good as fluid preload alone in combating the hypotension associated with spinal anaesthesia for Caesarean section.     

Evaluation of nutritional status in persons with spinal cord injury: a prerequisite for successful rehabilitation

A minority of patients with acute pulmonary embolism (PE) show failure of resolution when assessed by serial ventilation/perfusion (V/Q) radionuclide lung imaging. The fibrinolytic systems were studied in six such patients (group I), and in 11 patients in whom PE had resolved (group II), together with 17 healthy control subjects. Assays of the fibrinolytic system included euglobulin clot lysis times (ECLT), tissue plasminogen activator (tPA), and plasminogen activator inhibitor-1 (PAI-1). Euglobulin clot lysis times were not prolonged in the unresolved PE group, but were significantly longer in patients in group II when compared to control subjects (P < 0.03). This could not be explained either on the basis of tPA levels, which were higher in group II when compared to group I (P < 0.05) and control subjects (P < 0.02), or on the basis of PAI-1 levels which did not differ significantly between the three groups. Our inability to demonstrate derangements of fibrinolysis in the patients with unresolved PE makes defective fibrinolysis an unlikely aetiological factor in the persistence of thrombosis in these patients.     

Duration of spinal anaesthesia is determined by the partition coefficient of local anaesthetic

We have compared the duration of motor block produced by four local anaesthetics administered into a chronically implanted subarachnoid catheter in rabbits. Each group (n = 6) received four different doses of amethocaine, bupivacaine, lignocaine or procaine, and the duration of the resulting motor block was assessed. Dose-response curves were plotted for each drug. As a measure of activity of the anaesthetics, we used the dose of each drug required to produce block of 60-min duration (D60 min) and the correlation between D60 min and different drug properties was examined. An inverse linear correlation (r = 0.995; P < 0.01) was observed between log D60 min and the log of the partition coefficient of the local anaesthetics. No correlation was found between the effect and degree of protein binding, pKa or molecular weight. These results suggest that, in spinal anaesthesia, the partition coefficient could be used as a predictor of the duration of anaesthetic action.     

Acid-base state of cerebrospinal fluid during pregnancy and its effect on spread of spinal anaesthesia

To assess the possible relationship between changes in acid-base state of cerebrospinal fluid (CSF) and enhanced spread of spinal anaesthesia during pregnancy, we have measured CSF pH, carbon dioxide tension (PCO2) and HCO3- values in 73 women undergoing spinal anaesthesia with hyperbaric amethocaine 8 mg. Patients were allocated to one of four groups according to gestational period: non-pregnant group (n = 13), first trimester group (8-13 weeks, n = 19), second trimester group (14-26 weeks, n = 11) and third trimester group (27-39 weeks, n = 30). The pH of the CSF was greater in the second and third trimester groups than in the non-pregnant group. CSF PCO2 decreased by 0.53-0.8 kPa throughout pregnancy. CSF HCO3- was decreased throughout pregnancy. Overall, no clinically significant correlation was found between maximum cephalad spread of analgesia and CSF pH, PCO2 or HCO3-. We conclude that pregnancy-induced changes in acid-base state of CSF have little effect on the spread of spinal anaesthesia, although there is a clinically different spread of spinal anaesthesia between non-pregnant and pregnant states.