Use of paravertebral block anesthesia in the surgical management of breast cancer: experience in 156 cases

The purpose of this investigation was to determine whether the presence of selected disease-associated bacteria in health-associated plaque correlated with future gingivitis. Sites of periodontal health were identified in 65 adults. Six months later (recall 1) plaque was collected from sites that remained in periodontal health, and 5 species of specific bacteria and pathogen-related oral spirochetes were detected using monoclonal antibodies in a microscopic assay. Members of the spirochete morphogroup were also identified by phase contrast microscopy. The relationship between site-specific detection of bacteria at recall 1 and development of gingivitis at recall 2 or 3 was evaluated by means of logistic regression using generalized estimating equations, from which odds ratios (OR) were estimated. Significance was conservatively defined as OR > 2.0 and P < 0.05. We found that 488 of 1,424 healthy sites developed gingivitis over the 12-month interval between recall 1 and 3. Only the spirochete morphogroup (OR =2.04; P=0.002) was significantly associated with the transition from health to gingivitis. The association of Treponema socranskii with future gingivitis was higher than expected (OR=2.27), but the relationship was not statistically significant (P=0.163). Campylobacter rectus, Eikenella corrodens, Porphyromonas gingivalis, and pathogen-related oral spirochetes did not correlate well with gingivitis (OR < 2.0). Health-associated plaque from 5 sites contained Treponema denticola, and all 5 sites progressed to gingivitis. An OR could not be calculated because T. denticola was not detected in health-associated plaque from stable healthy sites. These findings indicated that the presence of T. denticola and unidentified spirochetes in health-associated plaque was associated with increased susceptibility to gingival inflammation. Future studies assessing a larger panel of dental plaque microorganisms, with shorter intervals between baseline and follow-up assessment, are necessary to more fully evaluate the association between detection of specific organisms at healthy sites and risk for gingivitis.     

CSE vs. augmented epidural anesthesia for cesarean section. Spinal and epidural anesthesia with bupivacaine 0.5% "isobar" require augmentation

Incomplete anaesthesia is a major clinical problem both in single spinal and in single epidural anaesthesia. The clinical efficacy of epidural anaesthesia with augmentation (aEA) and combined epidural and spinal anesthesia (CSE) for cesarean section was investigated in a prospective randomized study on 45 patients. METHODS: Anaesthesia extending up to Th5 was aimed for. Depending on the patient's height, epidural anaesthesia was administered with a dose of 18-22 ml 0.5% bupivacaine and spinal anaesthesia with a dose of 11-15 mg 0.5% bupivacaine. Augmentation was carried out in all cases in epidural anaesthesia, initially with 7.5 ml 1% Lidocaine with epinephrine 1:400,000, raised by 1.5 ml per missing segment. The epidural reinjection in CSE was carried out as necessary with 9.5-15 ml 1% lidocaine with epinephrine, depending on the height and difference from the segment Th5. RESULTS: The extension of anaesthesia achieved in epidural anaesthesia after an initial dose of 101.8 mg bupivacaine and augmenting dose of 99 mg lidocaine reached the segment Th5. The primary spinal anaesthesia dose up to 15 mg corresponding to height led to a segmental extension to a maximum of Th3 under CSE. Augmentation was necessary in 13 patients; in 5 cases because of inadequate extent of anaesthesia and 8 cases because of pain resulting from premature reversion. The augmenting dose required was 13.9 ml. Readiness for operation was attained after 19.8 min (aEA) and after 10.5 min (CSE). No patient required analgesics before delivery. The additional analgesic requirement during operation was 63.6% (aEA) and 39.1% (CSE). Taking into account pain in the area of surgery, the requirement of analgesics was 50% (aEA) vs. 17.4% (CSE). Antiemetics were required in 18.2 (aEA) and in 65.2% (CSE). The systolic blood pressure fell by 17.7% (aEA) and in 30.3% (CSE). The minimum systolic pressure was observed after 13.4 min in aEA, and after 9.5 min in CSE. The APGAR score and the umbilical pH did not show any differences. General anaesthesia was not required in any case.     

A chronic model for experimental investigation of epidural anesthesia in the rabbit

BACKGROUND/AIMS: By contrast with animal models, in most cases it is not possible to examine the systemic response in patients in the first hours after onset of acute pancreatitis. The aim was to determine whether endoscopic retrograde cholangiopancreaticography (ERP)-induced pancreatitis can be used as a human model for the study of cytokine release and acute phase response in the first hours of the disease. PATIENTS AND METHODS: Seventy consecutive patients undergoing ERP for different reasons were prospectively evaluated by sampling blood before and 0, 1, 4, 12, 24, and 48 hours after ERP and, in patients who developed an acute post-ERP pancreatitis, daily until C reactive protein (CRP) was within normal range. A post-ERP pancreatitis was defined as a three-fold increase of amylase or lipase and at least two of the clinical symptoms: abdominal pain, nausea, vomiting, and peritonism during 24 hours after ERP. RESULTS: Nine out of 70 patients developed an acute pancreatitis. Cytokines and other biochemical variables were measured in those nine and in 34 patients out of the 61 not developing pancreatitis. In the nine patients amylase and lipase increased within the first hour after ERP with maximum values between four and 12 hours. Interleukin-6 increased to maximal concentrations after 24-48 hours and the highest CRP concentrations were found 72 hours after ERP. Tumour necrosis factor did not change. CONCLUSION: Post-ERP pancreatitis is an ideal model in which to examine the initial cytokine and acute phase response in the first hours after the initiation of the disease.     

Use of epidural anesthesia and spontaneous ventilation during transabdominal colon and rectal procedures in selected high-risk patient groups

Fibrodysplasia ossificans progressiva (FOP) is a rare genetic disorder characterized by congenital malformation of the great toes and progressive heterotopic ossification in distinct anatomic patterns. Early preosseous lesions in FOP are clinically and histologically indistinguishable from the lesions of aggressive juvenile fibromatosis (AJF). Although the genetic defect in FOP is unknown, bone morphogenetic proteins (BMPs) 2 and 4 are plausible candidates genes. To determine if there is a difference in BMP 2/4 expression in the early fibromatous lesions of the two conditions, we performed immunohistochemical studies with a monoclonal antibody to BMP 2/4 on the earliest detectable fibromatous lesions of FOP and compared them with histologically identical lesions resected from children who had AJF. Fibromatous cells from the early FOP lesions exhibited immunostaining for BMP 2/4, whereas histologically indistinguishable fibromatous cells from AJF lesions showed no evidence of BMP 2/4 immunostaining. It is incumbent on all physicians who treat patients with suspected fibromatosis to examine the toes to rule out FOP and to avoid unnecessary diagnostic biopsies because surgical trauma induces further bone formation in patients who have FOP. However, if diagnostic confusion still exists and a biopsy is performed, immunostaining with BMP 2/4 antibody may resolve the diagnostic dilemma between FOP and AJF before the appearance of heterotopic ossification is observed in the FOP lesions. Our data suggest that the BMP 2/4 subfamily of secreted proteins may be involved in the pathogenesis of the FOP lesions.     

Safety of spinal and epidural anesthesia in parturients with chorioamnionitis

BACKGROUND AND OBJECTIVES: The safety of spinal and epidural anesthesia in patients with chorioamnionitis was explored. METHODS: A retrospective study was made of the charts of 517 parturients who had received epidural anesthesia and 14 who had received spinal anesthesia before delivery and whose placentas had subsequently been found to be positive for chorioamnionitis. RESULTS: Of the 146 blood culture results that were reported, 13 were positive. Of these 13 blood cultures, 5 had been drawn within 6 hours after placement of the epidural block, and four of the five bacteremic patients did not receive antibiotics until after the regional anesthetic was administered. One quarter (11/45) of the patients who were febrile and three quarters (174/229) of those who had leukocytosis before their block received no antibiotics before the block was placed. After the epidural block was performed, the catheter was left in place for over 24 hours in 18% (46/260) of the women who spiked a fever and in 14% (18/130) of those who exhibited leukocytosis during that period. There was no report of an epidural or spinal abscess or of meningitis in any of the women in the study. CONCLUSION: Conduction anesthesia may be safe in parturients with chorioamnionitis without prior antibiotic therapy.     

Sacrococcygeal and transsacral epidural anesthesia in the laboratory pig: a model for experimental surgery

We present a selected group of patients (18) who underwent excision of various malignant skin lesions in the leg, and had the defect resurfaced with V-Y advancement flaps. The mobility and reliability of this type of flap was enhanced by raising it as a fasciocutaneous flap based on one or two leg perforators. As patients were mobilised as soon as they recovered from the operation, there was minimal postoperative morbidity. This type of flap has the added advantage of leaving no significant donor defect and therefore better cosmesis.     

Combined spinal and epidural anesthesia. A review of the method

Combined spinal epidural anaesthesia (CSE) offers the fast and profound neural blockade of spinal anaesthesia, but provides the possibilities of extension of the block and post-operative pain control. On the basis of a historical review, the advantages and drawbacks of CSE are discussed, and purpose-designed needles (Eldor 1 and 2, E-SP, T-A, Braun, Mediziv) are described. The dosage problems inherent in the technique and a possible solution to the "test dose" question are described. In conclusion: CSE is a valuable alternative to established regional anaesthetic techniques. The Mediziv needle offers several advantages, but a comparative study of the different needle types is needed.     

Comparison of lidocaine and saline for epidural top-up during combined spinal-epidural anesthesia in volunteers

This study was designed to determine the efficacy of saline as an epidural top-up to prolong spinal anesthesia during combined spinal-epidural anesthesia (CSEA). Eight volunteers received three separate CSEAs with intrathecal lidocaine (50 mg). After two-segment regression, each subject received either a saline (10 mL), lidocaine 1.5% (10 mL), or control sham (0.5 mL saline) epidural injection in a randomized, double-blind, triple cross-over fashion. Sensory block was assessed by pinprick and tolerance to transcutaneous electrical stimulation (TES) equivalent to surgical stimulation at the knee and ankle. Motor strength was assessed with iso-metric force dynamometry. Data were analyzed with a repeated measures analysis of variance and a paired t-test. Sensory block to pinprick was prolonged in the thoracolumbar dermatomes only by lidocaine (P < 0.05). Neither lidocaine nor saline prolonged the duration of tolerance to TES at the tested sites. Instead, saline decreased the duration of tolerance to TES by 20 and 24 min at the knee and ankle (P < 0.05). Recovery from motor block at the quadriceps was prolonged by an epidural injection of lidocaine (P < 0.05). We conclude that when 10 mL of epidural saline is administered after two-segment regression, it is an ineffective top-up and may decrease the duration of spinal anesthesia during CSEA.     

A prospective evaluation of the value of preoperative laboratory testing for office anesthesia and sedation

PURPOSE: The purpose of this investigation was to determine whether routine laboratory testing affected the clinician's preoperative evaluation and decision-making process for patients undergoing general anesthesia or intravenous sedation in the oral and maxillofacial surgery office. PATIENTS AND METHODS: This was a prospective evaluation of the records of 458 who required an office general anesthetic or intravenous sedation for routine dentoalveolar surgery. The patients ranged in age from 15 to 54 years and were categorized as American Society of Anesthesiologists Classification I or II. Fifty-two percent were female. All patients underwent a history and physical examination, complete blood cell count, and urine analysis. Female patients were tested for pregnancy by measuring the serum beta human chorionic gonadotropin level. All patients older than 40 years of age were further evaluated by posterior-anterior and lateral chest radiographs, as well as electrocardiography. On the day of surgery, the data were reviewed and analyzed, and specific components of the history were reassessed. The results of the decision-making process were evaluated by one investigator. RESULTS: From the 458 patients initially enrolled, 78 failed to return on the appointed day. Of the 235 patients requiring general anesthesia who did return on the appointed day, five had aberrant laboratory values (2%). These consisted of one patient with a low hematocrit, one with a low red blood cell count, one with a low white blood cell count, and two with a urine analysis positive for blood. No procedure was canceled based on the aberrant data. Of the 145 patients requiring intravenous sedation who did return on the appointed day, six had aberrant laboratory values (4%). Two patients exhibited elevated white blood cell counts, two possessed low red blood cell counts, one known to have diabetes had an elevated urine glucose, and one patient with an elevated human chorionic gonadotropin level realized that her menstrual cycle was delayed. The latter two patients had their procedures deferred. CONCLUSIONS: Based on the results of this study, a good history and physical examination and then reassessment of key portions of the history were the major factors in the development of the anesthetic treatment plan. Laboratory data had little if any effect on the decision-making process.     

Combined spinal and epidural anesthesia for cesarean section in a parturient with moyamoya disease

We present the case of a parturient with moyamoya disease admitted to the hospital for elective cesarean section. Combined spinal and epidural technique was chosen because it allows better analgesia than epidural anesthesia and more hemodynamic stability than either general or spinal anesthesia. Ropivacaine was the local anesthetic of choice for the epidural portion because of the wide sensory-motor dissociation, thus preserving adequate respiration in the case of a high block.     

A comparison of ketamine and the combination ketamine-xylazine for effective surgical anesthesia in the rabbit

Ketamine alone and the combination ketamine-xylazine were evaluated as surgical anesthetics in rabbits. It was found that ketamine alone provided inadequate analgesia for ventral abdominal incisions or exposure of the femur. The combination of xylazine with ketamine did provide adequate enalgesia for both surgical procedures.     

Comparison of transthecal and subcutaneous single-injection digital block techniques in cadaver hands

Calmodulin-dependent protein kinase IV (CaM-kinase IV) is markedly activated on the phosphorylation of Thr196 by an upstream protein kinase, CaM-kinase kinase. The phosphorylation of CaM-kinase IV by CaM-kinase kinase is strongly suppressed on incubation with calmodulin in the presence of Ca2+, which results in a decrease in the enzyme activity, and completely restored on subsequent incubation with Mg2+ in the absence of Ca2+, which results in an increase in the activity. That a downstream protein kinase regulates its activity through reversible changes in its susceptibility to phosphorylation by an upstream protein kinase is a new regulatory mechanism.