Spinal anesthesia for elective lumbar spine surgery

STUDY OBJECTIVE: To evaluate a large series of elective lumbar spine surgical procedures by a single surgeon whose patients were all offered spinal anesthesia. DESIGN: Retrospective chart review. SETTING: Tertiary-care teaching hospital. MEASUREMENTS AND MAIN RESULTS: The records of all elective lumbar spine procedures between 1984 and 1995 performed by one surgeon (GRB) were obtained, and 803 were identified. Of those 803 patients, 611 accepted spinal anesthesia. Data collected included patient demographics, details of the spinal and general anesthesia, perioperative complications, and impact of the spinal anesthetic options on the outcome of spinal anesthesia. General and spinal anesthesia patients were comparable for age, gender, height, and ASA physical status. Patients who received spinal anesthesia were significantly heavier than the general anesthesia patients. Among perioperative complications, nausea and deep venous thrombosis occurred significantly more often in the general than spinal anesthesia patients. Mild hypotension and decreased heart rate (HR) were the most common hemodynamic changes with spinal anesthesia, whereas hypertension and increased HR were the result of general anesthesia. Among spinal anesthetic drugs, plain bupivacaine was associated with the lowest incidence of supplemental local anesthetic use intraoperatively compared to hyperbaric bupivacaine or hyperbaric tetracaine. CONCLUSION: Spinal anesthesia is an effective alternative to general anesthesia for lumbar spine surgery and has a reduced rate of minor complications.     

Outcome from day-case knee arthroscopy in a major teaching hospital

Outcome is presented for 465 knee arthroscopies performed under general anesthesia in a public teaching hospital day surgery unit. The unanticipated hospital admission rate on the day of surgery was 1.07%. There were 11 (2.37%) major complications in the combined perioperative and postdischarge periods (up to 4 weeks postdischarge). Surgery-related complications (incidence 1.08%) were more frequent than complications of anesthesia (0.65%). Four patients (0.86%) had delayed complications after discharge that required hospital readmission. Stepwise polychotomous logistic regression showed that these complications were not significantly related to patient age, sex, American Society of Anesthesiologists (ASA) status or type of surgery. Mean recovery times required for patients to sit out of bed and to be ready for discharge were 61 +/- 37 and 142 +/- 52 min, respectively. Both postoperative pain and postoperative nausea and vomiting, present in 76% and 11.5% of patients, respectively, significantly delayed patient recovery, with longer delays associated with nausea and vomiting. Times required for patients to be ready for discharge were not correlated to either patient age (r = 0.07; p = 0.15) or duration of procedure (r = 0.07; p = 0.13). At early follow-up, 4.7% and 2.5% of patients had presented to hospital accident and emergency departments and local family doctors, respectively, usually for minor problems. Ninety-nine percent of all patients were happy with the ambulatory surgery service. With careful patient assessment and selection, day-case knee arthroscopy in a teaching hospital can provide satisfactory outcome.     

General anesthesia for an infant with Rubinstein-Taybi syndrome

A 5-year-old girl with Rubinstein-Taybi syndrome (RTS) was scheduled for ophthalmic surgery under general anesthesia. RTS is a well-defined syndrome with facial abnormalities including a high palate and micrognathia, broad thumbs and big toes, and mental retardation as main clinical features, which may be complicated with repeated respiratory infections, cardiac anomalies, and so on. Anesthesia was uneventfully induced and maintained with the inhalation of oxygen, nitrous oxide and sevoflurane. Special attention was paid to the possibilities of the difficult airway, aspiration pneumonia and cardiovascular dysfunction during anesthesia. No complications were observed throughout the perioperative procedures.     

Anesthetic management of a child with Lenz dysplasia associated with panhypopituitarism

We present a child with Lenz dysplasia associated with panhypopituitarism. Lenz dysplasia is characterized by small eyeball, small head, hydronephrosis, cleft lip and palate, and mental retardation. A 12 month-old boy with Lenz dysplasia was scheduled for plasty of the lip and basis of the nasal cavity under general anesthesia. We had to pay attention for airway management and hormone supplementation. Anesthesia was induced with sevoflurane and nitrous oxide in oxygen. Tracheal intubation was facilitated with vecuronium bromide. We had no difficulty in airway management. Since this patient could not release enough endogenous cortisol in response to the stress of surgery, we supplemented hydrocortisone after anesthesia induction. Urine output and serum electrolyte concentrations were carefully monitored during surgery because of the impaired ADH response. We encountered no complications in the anesthetic management of this patient.     

Sleep-related respiratory disorders

Sleep-related respiratory disorders are mainly represented by the consequences of partial or total upper airway obstruction during sleep, which lead to clinical pictures ranging from "pure" snoring to full-blown obstructive sleep apnea syndrome, including obstructive sleep hypopnea syndrome and upper airway resistance syndrome. These pictures share symptoms like snoring and excessive daytime sleepiness. Beyond the social and professional impairment and the increased risk of traffic and work accidents, these patients are exposed to the complications of systemic hypertension, which is often associated, and of less frequent cardiorespiratory failure. The diagnosis is based upon polysomnography which demonstrates the ventilation abnormalities. Since stable weight loss is most often impossible to obtain, the treatment of choice is based on nasal continuous positive airway pressure during sleep. In some selected cases, facial bone surgery may be helpful.     

The incidence of complications associated with local anesthesia in dentistry

Local anesthetics are frequently administered in dentistry and thus can be expected to be a major source of drug-related complications in the dental office. Additionally, the dentist will more often be confronted with the treatment of risk patients; thus, the incidence of side effects can be expected to rise. In this study, 2731 patients receiving dental anesthesia were evaluated by questionnaire for risk factors, type and dosage of local anesthetic applied, type and duration of treatment, and complications associated with the administration of the local anesthetic. Of all patients, 45.9% had at least one risk factor in their medical histories, with cardiovascular diseases and allergies being the most frequent. The overall incidence of complications was 4.5%. It was significantly higher in risk patients (5.7%) than in nonrisk patients (3.5%). The most frequently observed complications (dizziness, tachycardia, agitation, nausea, tremor) were transient in nature and did not require treatment. Severe complications (seizure, bronchospasm) occurred in only two cases (0.07%). Articaine was found to be administered in over 90% of all dental anesthesias in Germany despite the great variety of local anesthetics available. Articaine 1:100,000 caused more sympathomimetic side effects than did articaine 1:200,000. Additionally, doses of local anesthetics proved not to be strictly determined according to body weight, especially for patients weighing less than 50 kg. In summary, it can be stated that dental local anesthesia can be considered safe. Nevertheless, the incidence of complications due to dental anesthesia can be expected to be further reduced if (a) patients are routinely evaluated for risk factors with an adequate medical history prior to dental treatment, (b) doses of local anesthetics are strictly determined according to body weight, (c) anesthetics with low concentrations of epinephrine are used, and (d) the concept of a differentiated dental anesthesia is applied.     

Tracheostomy in the young pediatric burn patient

OBJECTIVE: To evaluate the incidence of complications in comparison with the benefits of tracheostomy in young pediatric burn patients (newborn to 3 years old). DESIGN: Retrospective survey. SETTING: Tertiary care burn center. PATIENTS: A total of 1549 consecutive pediatric burn patients, of whom 180 were intubated. INTERVENTIONS: Tracheostomy was performed in 76 children. MAIN OUTCOME MEASURES: Duration of mechanical ventilation, mortality, respiratory complications, airway complications, and condition of the airway at discharge from the hospital. RESULTS: Seventy-six patients required tracheostomy. Their mean burn size was 34% total body surface area and mean length of stay in the hospital was 56 days. There were no perioperative complications. Eight patients (10%) could not be decannulated because of airway obstruction. Five of these outgrew their obstruction, 2 required surgery, and 1 continues to be evaluated for laryngeal reconstruction. CONCLUSION: Pediatric tracheostomy can be performed safely with no perioperative complications and acceptable chronic morbidity.     

Risk factors for neurologic deterioration after revascularization surgery in patients with moyamoya disease

To investigate the risk factors for postoperative neurological deterioration in patients with moyamoya disease, we retrospectively reviewed the perioperative course of 368 cases of revascularization surgery in 216 patients with this disease. Risk factors anecdotally associated with postoperative ischemic events were analyzed by comparing groups with or without a history of such events on the operative day. Ischemic events were noted in 14 cases (3.8%), 4 of which were defined as strokes and the others as transient ischemic attack (TIA). Postoperative neurological deterioration more often developed in patients who suffered from frequent TIAs, had precipitating factors for TIA, and underwent indirect nonanastomotic revascularization. The authors conclude that the incidence of postoperative ischemic events were related more to the severity of moyamoya disease and the type of surgical procedure than to other factors, including anesthetic management. IMPLICATIONS: Although preventing stroke is the major concern for patients with moyamoya disease, risk factors for perioperative cerebral ischemia have not been clarified. We retrospectively analyzed the perioperative course in 368 cases with this disease and found that the severity of the disease and type of surgical procedure were major determinants of postoperative cerebral ischemia.     

The laryngeal mask in pediatric anesthesia

We carried out a perspective study in order to assess the ease of insertion, the type and the incidence of perioperative complications connected with the use of the Laryngeal Mask Airway (LMA). We examined 300 consecutive patients, M/F 261/39, average age 4.2 yrs. (range 0.1-16), ASA I-II, who underwent surgical operations of short or average length not involving the pleural, the oropharyngeal or the peritoneum cavity. The choice about anesthesia was left to the discretion of the anesthesiologist. In 27 cases the position of the LM was controlled through a flexible fiberoptics. In 269 patients (89.6%) the LMA was correctly positioned during the first attempt. In 27 patients (9%), 2 or more attempts were necessary, and in 4 patients (1.4%) it was not possible to set the LMA. No differences of statistical significance were noticed between the different size of LMA, with regards to the facility of insertion. The control through fiberoptics showed a correct position, from an anatomical point of view, in 11 patients (41%), whereas in 13 patients (48%) some signs of partial obstruction were noticed (epiglottis interposing between the opening of LMA and larynx) and in 3 patients (11%) vocal cords are not visible. The following complications took place: laryngeal spasm on induction (2.3%), cough or movements on positioning (2.3%), hypoxia (4.3%), obstruction (1%), laryngeal spasm on awakening (1.7%), trauma (5%) and vomiting (0.3%). No connections were found between the size of LMA and total complications. Nevertheless, cough or movement during positioning and laryngeal spasm on awakening were significantly more frequent with LMA n. 3. In our experience, the LMA proved to be effectual and safe in the control of the airway during elective operations in pediatric surgery.     

A new experimental device for the measurement of moisture emission and heat release from respiratory organs and body surface

BACKGROUND: The majority of patients with peripheral vascular disease have associated medical illnesses that contribute to a substantial incidence of perioperative complications. Some of the these complications may be related to the choice of anesthetic used. An ideal anesthetic would provide good analgesia, have few complications associated with its use, including minimizing hemodynamic instability, and provide an adequate surgical environment. MATERIALS AND METHODS: Ten patients with an occluded superficial femoral artery and claudication or rest pain were selected. Eligibility criteria were a non-obese thigh and an above knee popliteal segment of at least 10 cm. Lidocaine local anesthesia with systemic sedation was employed. Above knee femoropopliteal bypasses were performed in all patients. Intraoperative fluid volume, anesthetic dose and perioperative morbidity were recorded. RESULTS: All patients tolerated the procedure well. The operating environment was excellent. Intraoperative fluid requirements were less for patients receiving local anesthesia as compared with a similar group of patients undergoing above knee femoropopliteal bypass receiving regional anesthesia (mean 1750 ml versus 3386 ml). The mean dosage of lidocaine (0.5%) was 367 mg over a mean of 116 min operating time. All patients ambulated within 8 hours. There was no perioperative morbidity, mortality or graft occlusion. CONCLUSION: This technique is easy to perform and further reduces the systemic magnitude of anesthesia, while providing excellent perioperative analgesia and a satisfactory surgical environment. It may be ideal for the high risk patient, as intraoperative fluid volume requirements are reduced. In an era where endoluminal bypass grafting is being increasingly advocated, this technique retains the benefits of bypass grafting while possibly reducing the physiological insult.     

Management of ophthalmic complications of homocystinuria

OBJECTIVE: To determine the safety and efficacy of surgical versus medical management in the treatment of ophthalmic complications of homocystinuria, and also to document ocular complications of homocystinuria other than lens dislocation. DESIGN: Retrospective case series. PARTICIPANTS: Forty-five patients with ophthalmic complications of homocystinuria participated. INTERVENTION: Eighty-four surgical procedures were performed on 40 patients. There were 82 procedures done with the patients under general anesthesia and 2 with the patients under local anesthesia. Medical therapy was attempted initially in all patients with lens dislocation and was the sole therapy used for five patients. MAIN OUTCOME MEASURES: Complications resulting from medical or surgical treatment and final visual acuity were studied. RESULTS: All patients had a history of lens subluxation or dislocation. Fourteen (31%) were receiving dietary treatment at the time of presentation and 29 (64%) were mentally retarded. Eighty-two procedures were performed with the patients under general anesthesia with 2 surgical complications and 1 postsurgical complication. Lens dislocation into the anterior chamber was the most frequent indication for surgery (50%) followed by pupillary block glaucoma (12%). Prophylactic peripheral iridectomy was not successful in preventing lens dislocation into the anterior chamber in five patients. Anesthetic precautions such as stockings to prevent deep venous thrombosis, preoperative hydration, or aspirin were given in 85% of cases. Other common ophthalmic complications found include optic atrophy (23%), iris atrophy (21%), anterior staphylomas (13%), lenticular opacities (9%), and corneal opacities (9%). CONCLUSION: Laser iridectomy was unsuccessful in preventing lens dislocation into the anterior chamber. With appropriate anesthetic precautions and modern microsurgical techniques, the risks associated with the surgical management of ocular complications of homocystinuria are reduced. Surgical treatment should be considered, especially for cases of repeated lens dislocation into the anterior chamber or pupillary block glaucoma. If a conservative, nonsurgical approach is undertaken, these patients must be observed carefully for repeat episodes of lens dislocation.     

Thyroid gland surgery at the 1st Surgical Clinic of the 1st Medical School of Charles University and General Medical School Hospital in Prague--review of problems

The authors analyze a group of 100 patients indicated for goitrectomy during the period from 1995-1996. The most frequent indication for surgery was an eufunctional polynodular goitre. The group comprised 86 women and 14 men. Their mean age was 47 years, bilateral affections predominated. The most frequent type of operation was total thyroidectomy. Carcinoma was found in three of the operated patients. The mean period of hospitalisation was 6 days. Postoperative complications were more frequent after total goitrectomies, and with the extent of the operation the number of possible complications increased. The most serious complication in the authors opinion was a lesion of the parathyroid glands, observed in 5% of the patients. Permanent unilateral lesions of the recurrent nerve were recorded in 2% of the operated patients. There was no lethal postoperative complication. The largest operated goitre weighed 625 g (photograph 1). The authors conclude that it cannot be stated that the operation of larger goitres is associated with the highest incidence of postoperative complications. The opposite is rather the case.     

Complications of endoscopic sinus surgery: analysis of 2108 patients--incidence and prevention

The incidence of complications of endoscopic sinus surgery (ESS) in a combined experience with 2108 total patients is compared to complications in 11 other series of patients (2583 total) who underwent ESS and 6 series of patients (2110 total) who underwent traditional endonasal sinus surgery. The incidence of major perioperative complications was 0.85%, with cerebrospinal fluid (CSF) leak being the most common. The most common minor complications of ESS were those related to orbital penetration and middle turbinate adhesions; minor complications occurred in 6.9% of the 2108 patients. There were no statistically significant differences in the overall incidences of major complications between this series and the other two groups. Recommendations are made for the prevention of complications during ESS.     

Absence of cyclin D1 protein expression in splenic marginal zone lymphoma

We studied the endoscopic removal of tracheobronchial foreign bodies from 13 patients. Eight patients were treated under local anesthesia and 5 under general anesthesia. Complications included mild bleeding during endoscopic treatment of 3 patients. One patient was placed under general anesthesia because the patient was irritable and because hemorrhage made observation difficult. Laryngeal masks were used in 4 cases, and resulted in no complications. The follow-up courses ranged from 4 months to 12 years and were uneventful for all patients. Use of a fiberoptic bronchoscope in combination with laryngeal masks facilitated the management and removal of tracheobronchial foreign bodies by providing a secure airway and by minimizing the effect on the cardiorespiratory system.     

Advantages of epidural anesthesia in patients with end-stage chronic renal failure

The authors analyze the experience gained in anesthesiological management of 667 surgeries in patients with the end-stage chronic renal failure. 206 patients were operated on under epidural anesthesia and 461 under general anesthesia. The technique of anesthesia, preparation of patients, and the management during and after surgery are described. 63 hemodialysis procedures were performed for 4 h before and 154 for 12 h after surgery. The complications occurring during and after anesthesia by both methods are analyzed. Epidural anesthesia was found to be more safe for patients with the end-stage chronic renal failure. General anesthesia more often led to hemodynamic, respiratory, metabolic disorders, and other hemostasis disturbances.     

Transient Horner's syndrome after lumbar epidural anesthesia

Horner's syndrome as a complication of lumbar epidural anesthesia is a relatively benign and transient condition that usually does not warrant further extensive investigation. Its occurrence is unpredictable, although more frequently associated with epidural anesthesia performed for obstetric conditions. It may indicate high sympathetic blockade, and those patients should be monitored closely for autonomic complications. We report two new cases of iatrogenic Horner's syndrome from lumbar epidural anesthesia.     

Carotid endarterectomy under regional (conductive) anesthesia

Carotid endarterectomy is reliable in the prevention of strokes due to arteriosclerotic disease at the carotid bifurcation. This is a retrospective review of 314 carotid endarterectomies performed at the University Health Center of Pittsburgh. The objectives of the study were to determine if regional anesthesia was a safe technique for carotid endarterectomy and to determine whether the neurologic complications that occurred were embolic or ischemic in origin. In patients who were neurologically intact before operation, the perioperative mortality was 0.88% and the incidence of neurologic complications was 3.1%. This is comparable to the current literature. Observations of the awake patient suggested that half the neurologic deficits that occurred in this series were due to embolization rather than to cerebral ischemia. Further more, the incidence of non-neurologic complications under general anesthesia was 12.9%. Under regional anesthesia, the incidence of non-neurologic complications was 2.8%. The data supports carotid endarterectomy under regional block as safe and reliable method.     

Prevention of respiratory complications after abdominal surgery

Abdominal surgery, especially upper abdominal surgical procedures are known to adversely affect pulmonary function. Pulmonary complications are the most frequent cause of postoperative morbidity and mortality. This review article aimed to analyse the incidence and risk factors for postoperative pulmonary morbidity and their prevention. The most important means for preoperative assessment is the clinical examination; pulmonary function tests (spirometry) are not reliably predictive for postoperative pulmonary complications. Age, type of surgical procedure, smoking and nutritional state have all been identified as potential predictors for postoperative complications. However, usually there is not enough preoperative time available to obtain beneficial effects of stopping smoking and improvement of nutritional state. In patients with COPD, a preoperative multidisciplinary evaluation including the primary care physician, pulmonologist/intensivist, anesthesiologist and surgeon is required. Consensus as to preoperative physiologic state, therapeutic preparation, and postoperative management is essential. Simple spirometry and arterial blood gas analysis are indicated in patients exhibiting symptoms of obstructive airway disease. There are no values that contra-indicate an essential surgical procedure. Smoking should stop at least 8 weeks preoperatively. Preoperative therapy for elective surgery with antibiotics, beta2-agonist, or anticholinergic bronchodilator aerosols, as well as training in cough and lung expansion techniques should begin at least 24 to 48 hours preoperatively. Postoperative therapy should be continued for 3 to 5 days. Usually, anaesthesia is responsible for early complications, whereas surgical procedures are often associated with delayed morbidity. Laparoscopic procedures are recommended, as postoperative morbidity and hospital stay seem reduced in patients without COPD. Regional anaesthesia is given as having less adverse effects on pulmonary function than general anaesthesia. However, for unknown reasons these benefits are not associated with a decrease in postoperative respiratory complications. Moreover, the quality or the type of postoperative analgesia does not influence postoperative respiratory morbidity. Postoperatively, oxygen administration increases SaO2, but cannot abolish desaturation due to obstructive apnea. The various techniques of physiotherapy (chest physiotherapy, incentive spirometry, continuous positive airway pressure breathing) seem to be equivalent in efficacy; but intermittent positive pressure breathing has no advantages, compared with the other treatments and could even be deleterious. Chest physiotherapy and incentive spirometry are the most practical methods available for decreasing secretion contents of airways, whereas continuous positive airway pressure breathing is efficient on atelectasis. In stage II or III COPD patients, admission in a intensive therapy unit and prolonged mechanical ventilation may be required.