Complications during and after surgery and childbirth where spinal or epidural analgesia is used. Guidelines for safe practice

When complications and neurological sequelae occur during a spinal or epidural anaesthetic the causes are clearly related to the procedures in the following cases: severe haemodynamic or respiratory derangement, documented needle trauma of nerve fibres, intraspinal haematoma in anticoagulated or heparinized patients, and epidural infection where an infected epidural catheter entry site is documented. A number of well documented cases have been published in which surgery or patient-related pathology were primary causes of "typical" spinal or epidural neurological complications. These emphasize the importance of searching for other risk factors of neurological sequelae after surgery or child birth in cases where there is no obvious deviation from the normal epidural or spinal procedures. Increased focus on the infrequent, but serious complications of these essentially very safe techniques for surgical anaesthesia and pain relief should serve to increase our vigilance, but should not reduce the application of spinal and epidural analgesia. Guidelines are offered for the effective and safe practice of spinal and epidural anaesthesia and pain relief: adequate supervision of trainee anaesthetists, vigilant monitoring for early detection and handling of complications, and trained nurses on surgical wards to monitor and handle patients during epidural analgesia are important. Sufficient readiness for urgent handling of the very rare, but devastating complications of intraspinal bleeding or infection is an absolute necessity.     

Motor deficit of the lower limbs and urinary incontinence following peridural anesthesia

Neurological complications of epidural anaesthesia are rare, but can be severe. We report the case of a 49-year-old man, with a history of non equilibrated diabetes, who experienced after an epidural anaesthesia for peripheral vascular surgery a polyneuropathy with muscle weakness of the lower extremities associated with a transient urinary incontinence. A spinal compression was excluded by computed tomography and magnetic resonance imaging. Electromyography showed an impaired nervous motor conduction. An aggravation of a pre-existing diabetic and alcoholic polyneuropathy, associated with possible spinal ischaemia of multifactorial origin could be the cause of these complications. This case emphasizes the importance, during preanesthetic assessment of candidates for epidural or spinal anaesthesia, to search for a possible unrecognized neuropathy at risk of aggravation by regional anaesthesia.     

Perioperative ischaemia in aortic surgery: combined epidural/general anaesthesia and epidural analgesia vs general anaesthesia and i.v. analgesia

PURPOSE: The goal of this randomized study was to determine whether combined general and epidural anaesthesia with postoperative epidural analgesia, compared with general anaesthesia and postoperative intravenous analgesia, reduced the incidence of perioperative myocardial ischaemia in patients undergoing elective aortic surgery. METHOD: Patients were randomly assigned to one of two groups. One group (EPI, n = 48) received combined general and epidural anaesthesia and postoperative epidural analgesia for 48 hrs. The other group (GA, n = 51) received general anaesthesia followed by postoperative intravenous analgesia. Anaesthetic goals were to maintain haemodynamic stability (+/- 20% of preoperative values), and a stroke volume > 1 ml.kg-1. A Holter monitor was attached to each patient the day before surgery. Leads 11, V2, and V5 were monitored. Myocardial ischaemia was defined as ST segment depression > 1 mm measured at 80 millisec beyond the J point or an elevation of 2 mm 60 millisec beyond the J point which lasted > 60 sec. An event that lasted > 60 sec but returned to the baseline for > 60 sec and then recurred, was counted as two separate events. The Holter tapes were reviewed by a cardiologist blind to the patient's group. RESULTS: There were no demographic differences between the two groups. Myocardial ischaemia was common; it occurred in 55% of patients. In hospital, preoperative ischaemia was uncommon (GA = 3, EPI = 8). Intraoperative ischaemia was common (GA = 18, EPI = 25). Mesenteric traction produced the largest number of ischaemic (GA = 11, EPI = 11) events. Postoperative ischaemia was most common on the day of surgery. Termination of epidural analgesia produced a burst of ischaemia (60 events in 9 patients). CONCLUSION: Combined general and epidural anaesthesia and postoperative epidural analgesia do not reduce the incidence of myocardial ischaemia or morbidity compared with general anaesthesia and postoperative intravenous analgesia.     

Enhancing versus suppressive effects of stress hormones on skin immune function

Delayed-type hypersensitivity (DTH) reactions are antigen-specific cell-mediated immune responses that, depending on the antigen, mediate beneficial (e.g., resistance to viruses, bacteria, and fungi) or harmful (e.g., allergic dermatitis and autoimmunity) aspects of immune function. Contrary to the idea that stress suppresses immunity, we have reported that short-duration stressors significantly enhance skin DTH and that a stress-induced trafficking of leukocytes to the skin may mediate this immunoenhancement. Here, we identify the hormonal mediators of a stress-induced enhancement of skin immunity. Adrenalectomy, which eliminates the glucocorticoid and epinephrine stress response, eliminated the stress-induced enhancement of skin DTH. Low-dose corticosterone or epinephrine administration significantly enhanced skin DTH and produced a significant increase in the number of T cells in lymph nodes draining the site of the DTH reaction. In contrast, high-dose corticosterone, chronic corticosterone, or low-dose dexamethasone administration significantly suppressed skin DTH. These results suggest a role for adrenal stress hormones as endogenous immunoenhancing agents. These results also show that hormones released during an acute stress response may help prepare the immune system for potential challenges (e.g., wounding or infection) for which stress perception by the brain may serve as an early warning signal.     

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.     

The epidural use of morphine and alpha 2-agonists for postoperative analgesia

Three protocols of postoperative pain relief after gastric surgery were used in 60 male patients: regular intramuscular morphine, epidural morphine, and epidural morphine with 0.1 mg of clonidine. Pain relief was more effective with the epidural route of administration. Addition of clonidine in a daily dose of 0.1 mg allowed a twofold decrease of epidural morphine dose, involving lesser hyperdynamic postoperative cardiovascular changes and complete elimination of psychotic complications and delirium in alcohol-dependent patients.     

Metabolic changes during recovery in normothermic versus hypothermic patients undergoing surgery and receiving general anesthesia and epidural local anesthetic agents

BACKGROUND: Mild hypothermia is accompanied by metabolic changes. Epidural local anesthetic agents attenuate the surgical stress response, but it is not known whether they modulate thermal stress. METHODS: Thirty patients undergoing colorectal surgery, performed by one surgical team, received epidural 0.5% bupivacaine to achieve T3-S5 sensory block. They were then assigned randomly to two groups of 15 patients each. The control or unwarmed group was left to cool during surgery, whereas active warming was used in the warmed group. General anesthesia was induced by thiopentone, vecuronium, fentanyl, nitrous oxide in oxygen, and enflurane. At the end of surgery, both groups received epidural 0.25% bupivacaine to maintain a T5-L3 sensory block. Aural canal (core) and skin surface (15 sites) temperatures; oxygen consumption; pain visual analogue score; and concentrations of epinephrine, norepinephrine, glucose, cortisol, lactate, and free fatty acids in plasma were measured before epidural blockade, 30 min after epidural blockade, at the end of surgery, and for 4 h after surgery. Patients and those measuring the outcomes were unaware of group allocation. RESULTS: Core and mean skin temperatures decreased significantly in the control group (P < 0.001) but not in the warmed group. Catecholamine concentrations in plasma decreased significantly after epidural block, and although concentration of epinephrine in plasma increased from baseline sharply in the control group at the end of surgery (P = 0.004), it decreased in the warmed group (P = 0.007). During recovery, there was no difference between the two groups for norepinephrine concentrations in plasma, body weight-adjusted oxygen consumption, pain visual analogue score, and metabolites. CONCLUSIONS: The postoperative metabolic changes obtained with epidural block were similar except for an attenuated concentration of epinephrine in normothermic patients compared with those who were mildly hypothermic.     

Thoracic epidural anaesthesia for coronary artery bypass graft surgery. Effects on postoperative complications

We have performed a retrospective analysis of the peri-operative course of 218 consecutive patients who underwent routine coronary artery bypass graft surgery in this institution. All patients received a standardised general anaesthetic using target-controlled infusions of alfentanil and propofol. One hundred patients also received thoracic epidural anaesthesia with bupivacaine and clonidine, started before surgery and continued for 5 days after surgery. The remaining 118 patients received target-controlled infusion of alfentanil for analgesia for the first 24 h after surgery, followed by intravenous patient-controlled morphine analgesia for a further 48 h. Using computerised patient medical records, we analysed the frequency of respiratory, neurological, renal, gastrointestinal, haematological and cardiovascular complications in these two groups. New arrhythmias requiring treatment occurred in 18% of the thoracic epidural anaesthesia group of patients compared with 32% of the general anaesthesia group (p = 0.02). There was also a trend towards a reduced incidence of respiratory complications in the thoracic epidural anaesthesia group. The time to tracheal extubation was decreased in the epidural group, with the tracheas of 21% of the patients being extubated immediately after surgery compared with 2% in the general anaesthesia group (p < 0.001). There were no serious neurological problems resulting from the use of thoracic epidural analgesia.     

Thoracic epidural analgesia in aortocoronary bypass surgery. II: Effects on the endocrine metabolic response

Thoracic epidural analgesia (TEA) may offer haemodynamic benefits for patients with coronary heart disease going through major surgery. This may-in part-be secondary to an effect on the endocrine and metabolic response to surgery. We therefore investigated the effect of TEA on the endocrine metabolic response to aortocoronary bypass surgery (ACBS). Thirty male patients (age < 65 years, ejection fraction > 0.5) were randomized into 3 groups; the HF group receiving a high dose fentanyl (55 micrograms.kg-1) anaesthesia, the HF+TEA group with the same fentanyl dose+TEA with 10 ml bupivacain 5 mg.ml-1, followed by 4 ml every hour, and the LF+TEA group receiving fentanyl 15 micrograms.kg-1 + TEA. Adrenalin, noradrenalin, systemic vascular resistance (SVR), glucose, cortisol, lactate and free fatty acids were followed during the operation and for 20 h postoperatively. A significant increase in adrenalin, noradrenalin and SVR was found in the HF group whereas this increase was blocked in both epidural groups. An increase in glucose and cortisol was noticed in all groups, but the increase was delayed in the epidural groups. Our results suggest that a more effective blockade of the stress response during ACBS is obtained when TEA is added to general anaesthesia than with high dose fentanyl anaesthesia alone.     

Risks and recommendations in Bechterew disease. Paraparesis after epidural anesthesia

We describe a case of paraparesis caused by an epidural haematoma in a 74-year-old man with advanced ankylosing spondylitis who received combined epidural and general anaesthesia for graft repair of an aneurysm of the abdominal aorta. Before the induction of general anaesthesia, an epidural catheter was inserted at the level of thoracic vertebrae 10-11 without difficulty or signs of bleeding. Total analgesia and paralysis of the legs in the early postoperative period raised suspicions of the presence of an epidural haematoma, which was confirmed by magnetic resonance tomography. Aspiration of the epidural catheter yielded 13 ml of blood. Despite early surgical decompression after transfer to a regional hospital, the patient remains paraparetic. We wish to highlight the risks of epidural anaesthesia in cases of ankylosing spondylitis, and to stress the need of routine control of motor function after epidural anaesthesia.     

Analgesia after surgery of the shoulder

Postoperative pain after shoulder surgery is known to be intense and requires usually opioid administration. The recent use of regional anaesthesia for this type of surgery has contributed to the relief of acute postoperative pain occurring in the recovery room since the analgesic effects of block persist for several hours after surgery depending upon the selected drug. Moreover, the development of less invasive surgery (arthroscopy) and experience with regional blocks have permitted to perform minor shoulder surgery on an outpatient basis. For minor surgery, regional anaesthesia associated to a light sedation is sufficient. However, for more invasive surgery, regional anaesthesia should be associated to a light general anaesthesia as well as the insertion of a supraclavicular catheter for postoperative analgesia. A diaphragmatic paresis secondary to a blockade of the phrenic nerve is constant radiologically after interscalenic block but remains symptomless. However, in case of severe preoperative chronic respiratory insufficiency, decompensation may occur rapidly after performance of the interscalenic block.     

Anesthesia in endovascular treatment of aortic aneurysm. Results and perioperative risks

Surgical treatment of aortic aneurysms carries significant cardiovascular risks. Transvascular insertion of endoluminal prostheses is a new, minimally invasive treatment for aortic aneurysms. The pathophysiology of this novel procedure, risks and benefits of different anaesthetic techniques, and typical complications need to be defined. METHODS: With their informed, written consent, 19 male patients aged 48-83 years of ASA physical status III and IV with infrarenal (n = 18) or thoracic (n = 1) aortic aneurysms underwent 23 stenting procedures under general endotracheal (n = 9), epidural (n = 8), or local anaesthesia with sedation (n = 6). Intra-anaesthetic haemodynamics, indicators of postoperative (p.o.) oxygenation and systemic inflammatory response, and perioperative complications were analysed retrospectively and compared between anaesthetic regimens. RESULTS: Groups were well matched with regard to morphometry and preoperative risk profiles (Table I). The use of pulmonary artery pressure monitoring, incidence of intraoperative hypotensive episodes, and p.o. intensive care was more frequent with general anaesthesia. Groups did not differ in total duration of anaesthesia care, incidence and duration of intraoperative hypertensive, brady-, or tachycardic periods, incidence of arterial oxygen desaturation, use of vasopressors, colloid volume replacements, or antihypertensives (Table 2). Postoperatively, all groups showed a similar, significant systemic inflammatory response, i.e., rapidly spiking temperature (p.o. evening: mean peak 38.5 +/- 1.0 degrees C). leucocytosis, and rise of acute-phase proteins without bacteraernia (Table 3). During this period, despite supplemental oxygen, pulse oximetry revealed temporary arterial desaturation in 13 of 18 patients (70%) (Table 3). In 3 patients, hyperpyrexia was associated with intermittent tachyarrhythmias (n = 3) and angina pectoris (n = 1). There was no conversion to open aortic surgery, perioperative myocardial infarction, or death. CONCLUSIONS: Regional and local anaesthesia with sedation are feasible alternatives to general endotracheal anaesthesia for minimally invasive treatment of aortic aneurysms by endovascular stenting. However, invasive monitoring and close postoperative monitoring are strongly recommended with either method. Specific perioperative risks in patients with limited cardiovascular or pulmonary reserve are introduced by the abacterial systemic inflammatory response to aortic stent implantation. Hyperpyrexia increases myocardial and whole-body oxygen consumption, and can precipitate tachyarrhythmias. Hyperfibrino-genaemia may increase the risk of postoperative arterial and venous thromboses. Close monitoring of vital parameters and prophylactic measures, including oxygen supplementation, low-dose anticoagulation, antipyretics, and fluid replacement are warranted until this syndrome resolves.     

Preoperative metoprolol improves cardiovascular stability and reduces oxygen consumption after thoracotomy

BACKGROUND: Increased sympathetic activity perioperatively and associated cardiovascular effects play a central role in cardiovascular complications. High thoracic epidural blockade attenuates the sympathetic response, but even with complete pain relief, haemodynamic and endocrine responses are still present. Beta-adrenoceptor blockade is effective in situations with increased sympathetic activity. This study was designed to evaluate the perioperative haemodynamic effect of preoperative beta-blockade and its influence on the haemodynamic aspects of the surgical stress response. METHODS: Thirty-six otherwise healthy patients undergoing elective thoracotomy for lung resection were randomised double-blinded to receive either 100 mg metoprolol or placebo preoperatively. Anaesthesia was combined high thoracic epidural block and general anaesthesia. The epidural analgesia was continued during recovery. Patients were monitored with ECG, pulse oximetry, invasive haemodynamic monitoring, arterial blood gases and electrolytes. RESULTS: After induction of anaesthesia the mean arterial pressure (MAP) decreased in both groups, and decreased further in the placebo group after initiation of the epidural block. The heart rate (HR) was slightly less throughout the observation period after metoprolol. Peroperatively, the only difference in measured haemodynamics was a marginally higher MAP after metoprolol. Postoperative cardiac index (CI) was lower with a lower variability and cardiac filling pressures were slightly higher in the metoprolol group. The oxygen consumption index was higher after placebo throughout the observation period, with no difference in the oxygen delivery. CONCLUSION: We found that preoperative beta-blockade during combined general anaesthesia and high thoracic epidural blockade stabilised perioperative HR and CI and decreased total oxygen consumption.     

Long-term treatment of bleeding caused by portal hypertension in children

We have compared the hypnotic requirements for i.v. thiopentone alone and in combination with i.m. lignocaine or bupivacaine. Ninety women, ASA I-II, undergoing minor gynaecological surgery were allocated randomly to nine groups of 10 patients to receive thiopentone combined with i.m. lignocaine, bupivacaine or saline, respectively. Thiopentone was administered in bolus doses of 0.5 mg kg-1 every 30 s until loss of response to verbal command. Lignocaine and bupivacaine significantly enhanced the hypnotic effect of thiopentone in a dose-dependent manner. The maximum doses tested (lignocaine 3.0 mg kg-1 and bupivacaine 1.0 mg kg-1) reduced the hypnotic dose of thiopentone by 39% and 48%, respectively. We conclude that if lignocaine or bupivacaine are injected into soft tissue before induction of anaesthesia by thiopentone, the i.v. dose of the latter should be modified accordingly.     

Role of 55- and 75-kDa TNF receptors in the potentiation of Fc-mediated phagocytosis in human neutrophils

OBJECTIVE: To compare the effect of epidural vs general anesthesia on the incidence of long-term cognitive dysfunction after total knee replacement surgery in older adults. DESIGN: Randomized controlled clinical trial. SETTING: Orthopedic specialty academic hospital. PATIENTS: A total of 262 patients undergoing elective primary total knee replacement with a median age of 69 years; 70% women. INTERVENTION: Random assignment to either epidural or general anesthesia. MAIN OUTCOME MEASURES: A thorough neuropsychological assessment was performed preoperatively and repeated at 1 week and 6 months postoperatively. Cognitive outcome was assessed by within-patient change on 10 tests of memory, psychomotor, and language skills. Prospective standardized surveillance for cardiovascular complications was performed to allow simultaneous assessment of anesthetic effects on cognitive and cardiovascular outcomes. RESULTS: The two groups were similar at baseline in terms of age, sex, comorbidity, and cognitive function. There were no significant differences between the epidural and general anesthesia groups in within-subject change from baseline on any of the 10 cognitive test results at either 1 week or 6 months. Overall, 5% of patients showed a long-term clinically significant deterioration in cognitive function. There was no difference between the anesthesia groups in the incidence of major cardiovascular complications (3% overall). CONCLUSIONS: The type of anesthesia, general or epidural, does not affect the magnitude or pattern of postoperative cognitive dysfunction or the incidence of major cardiovascular complications in older adults undergoing elective total knee replacement. This is the largest trial of the effects of general vs regional anesthesia on cerebral function reported to date, with more than 99% power to detect a clinically significant difference on any of the neuropsychological tests.     

Relationships of lipids to ovum size in amphibians

For many years, postoperative pain has been undertreated in children less than 5 years old in comparison to adults. The assessment of pain is indeed difficult in this range of age, and only the scales of hetero-evaluation are used. The guidelines for treatment are similar as in adults: systematic administration, balanced analgesia, evaluation of pain and potential adverse effects. Non opioid analgesics used are mainly paracetamol, niflumic acid and ibuprofen. Morphine remains the drug of choice among opioids; however the risk of respiratory depression in higher in infants less than 3 months old. Nalbuphine is also widely used in paediatrics. In addition, regional anaesthesia, either in single shot for minor surgery, or in continuous administration through epidural catheter for major surgery, has changed the management of postoperative pain in paediatrics.     

General anaesthesia for surgery can influence circulating melatonin during daylight hours

BACKGROUND: Both melatonin and anaesthetics have been shown to affect sleep and behaviour. The effect of general anaesthesia on circulatory melatonin has not been reported, but anaesthetic-related alterations in hormone profiles are known. We hypothesize that differences in recovery from anaesthesia may be associated with differences in circulatory melatonin levels because of melatonin's sedative effect in humans. METHODS: The influences of general anaesthesia and surgery on circulating melatonin, prolactin, and cortisol concentration were investigated in 32 female patients scheduled for elective gynaecological surgery to study differences in hormone profiles and responses during anaesthesia and the recovery period. Patients were randomly assigned to one of two groups. General anaesthesia was induced with either thiopentone/fentanyl (Group 1: n = 16) or propofol/fentanyl (Group 2: n = 16). Maintenance of anaesthesia was achieved with either isoflurane (0.8-1.0 vol%)/fentanyl (Group 1) or propofol (6 mg.kg-1.h-1)/fentanyl (Group 2) with a N2O/O2 flow ratio of 2:1 in both groups. During anaesthesia, patients' eyes were carefully taped shut to prevent light effects. Blood samples were taken before and after premedication, immediately before induction of anaesthesia, every 15 min during anaesthesia, and hourly in the recovery room for 8 h. The control group consisted of 6 healthy women who were not subjected to surgery, but who were in a similar environment, including light conditions, as the study groups. RESULTS: Isoflurane and propofol anaesthesia as well as darkness elicited elevated plasma melatonin levels that persisted in the recovery period in patients anaesthetized with isoflurane, but gradually decreased during the recovery of patients anaesthetized with propofol. Circulating prolactin and cortisol values were also elevated during anaesthesia and had similar decreases during the recovery period. CONCLUSION: Higher plasma levels of melatonin during the recovery period following isoflurane anaesthesia may, in part, explain increased sedation in these patients compared with patients who received propofol anaesthesia. However, the relationship between recovery from anaesthesia and plasma melatonin levels may not be simple and straightforward.     

Thoracic versus lumbar epidural anesthesia's effect on pain control and ileus resolution after restorative proctocolectomy

BACKGROUND: Epidural anesthesia as a perioperative adjunct has been shown to provide superior pain control and has been implicated in more rapid ileus resolution after major abdominal surgery, possibly through a sympatholytic mechanism. Studies suggest that the vertebral level of epidural administration influences these parameters. METHODS: One hundred seventy-nine patients (120 male, 59 female; average age, 36 years) underwent restorative proctocolectomy for ulcerative colitis or familial polyposis between 1989 and 1995. Patients were grouped according to type of anesthesia. Group THO (n = 53) received thoracic (T6 to T10) epidurals. Group LUM (n = 51) received lumbar (L2 to L4) epidurals, and group PCA (n = 75) received patient-controlled intravenous narcotic analgesia. Patients were compared for complications, perioperative risk factors, postoperative pain, and ileus resolution. RESULTS: Epidural narcotics, alone or combined with local anesthetics, were administered for an average of 2 (LUM) to 4 (THO) days without significant complications. Infrequent problems related to the epidural catheters included self-limited headaches or back pain (four) and site infections (two). Epidural failure, as measured by conversion to PCA for inadequate pain control, was not significantly greater for LUM (25%) than THO (23%). Average pain scores, rated daily on a visual analog scale, were significantly higher (indicating more pain) for PCA patients (4.2) during postoperative days 1 through 5 than for LUM (3.5) (p < 0.05) and for THO (2.4) (p < 0.05). Ileus resolution, as determined by stool output and return of bowel sounds, was significantly faster in THO than in LUM or PCA (p < 0.05). Resolution of ileus was not significantly different between PCA and LUM (p > 0.05). CONCLUSIONS: Thoracic epidural analgesia has distinct advantages over both lumbar epidural or traditional patient-controlled analgesia in shortening parameters measuring postoperative ileus and in reducing surgical pain. The procedure is safe and associated with low morbidity. Thoracic epidural anesthesia is also economically justifiable and may prove to impact significantly on future postoperative management by reducing length of hospitalization. Our data and those of others are most striking in these regards for patients with thoracic catheters, indicating the importance of vertebral level in epidural drug administration.     

A comparison of surgical and prosthetic treatment for speech disorders attributable to surgically acquired soft palate defects

Ophthalmic surgery is one of the most valuable indications for ambulatory anaesthesia (AA). Respecting the usual recommendations for AA and the specificity of ophthalmic surgery, AA has very few problems. In USA it concerns about 90% of ophthalmic surgery. Most of the patients are very young or very old. Adults are often poly-medicamented: diabetes and arterial hypertension are the most frequent pathologies. A lot of multivisceral pathologies are responsible of ocular diseases and can complicate anaesthesia. It is necessary to diagnose them before anaesthesia. Maligna hyperthermia risk is increased during strabismus and ptosis surgery. Some ocular treatments have systemic repercussion and require to be stopped before anaesthesia. Most of ophthalmic surgery can be practiced under any types of local anaesthesia. In postoperative of strabismus and retinal detachment repair, pain, nausea, vomiting are frequently observed. Their prevention is not very well known. The atropine used for cardiac reflex treatment may be responsible of an acute urine retention or a disorientation in elderly patients and delays the home readiness. Paper and pencil tests after general anaesthesia are very difficult to do, because requesting a good vision. The postoperative complications are essentially surgical complications.     

Laparoscopic cholecystectomy under epidural anesthesia in patients with chronic respiratory disease

BACKGROUND: Laparoscopic cholecystectomy (LC) has become firmly established as a procedure of choice for gallstone disease. The procedure usually necessitates general anaesthesia and endotracheal intubation to prevent aspiration and respiratory embarrassment secondary to the induction of pneumoperitoneum. There is a paucity of data in the literature on the procedure being performed under regional (epidural) anaesthesia, especially in patients with coexisting pulmonary disease and pregnancy, who are deemed high risk for general anaesthesia. We report our preliminary experience with LC using epidural anaesthesia in patients with chronic obstructive pulmonary disease (COPD). METHODS: We performed LC in six patients (one man and five women), with a median age of 56 years (range, 38-74), under epidural anaesthesia over an 8-month period. All patients were ASA grade III/IV and the mean FEB1/FVC was 0.52 (range, 0.4-0.68), due to chronic asthma (two cases) and COPD (four cases). They were admitted a day prior to surgery for pulmonary function tests, nebulisers, and chest physiotherapy. An epidural catheter was introduced at T10/11 intervertebral space, and a bolus of 0.5% Bupivacaine was administered. Depending on the patient's pain threshold and the segmental level of analgesia achieved, incremental doses of 2 ml of 0.5% Bupivacaine along with boluses of intravenous 100 mcg Alfentanil was given to each patient. The patients were breathing spontaneously. No nasogastric tube was inserted, and a low-pressure (10 mmHg) pneumoperitoneum was created. LC was performed according to the standard technique. RESULTS: All the patients tolerated the procedure well and made an uneventful postoperative recovery. Median operating time was 50 min; average length of hospital stay was 2.5 days (range, 2-4). The epidural catheter was removed the morning after the operation. Only one patient required postoperative opioid analgesia. Two patients complained of persistent shoulder tip pain during surgery and required intraoperative analgesia (Alfentanil). There was no change in the patient's cardiorespiratory status, including PO2 and pCO2, and no complications occurred either intra- or postoperatively. CONCLUSIONS: LC can be performed safely under epidural anaesthesia in patients with severe COPD. Intraoperative shoulder tip or abdominal pain does not seem to be a major deterrent and can be effectively controlled with small doses of opioid analgesia.