Biomedical subjects
Publications and source records attributed to A B Loach.
We describe a patient with unexpected spina bifida who underwent spinal anaesthesia for trans-urethral resection of prostate and developed serious neurological signs. An unexpected spinal tumour was removed two weeks later. This report demonstrates that not all neurological problems associated with spinal anaesthesia should be blamed on the technique.
A prospective study of the effectiveness of local anaesthesia in arthroscopy of the knee was performed in 212 consecutive patients. Arthroscopic surgery was undertaken successfully in 121 cases (57%), including meniscectomy and drilling of osteochondral defects. Dynamic evaluation of the patellofemoral joint articulation was possible and demonstration of pathological abnormalities was felt to be beneficial by some patients. The method described is safe, reliable, confers good postoperative analgesia and enables physiotherapy to begin immediately. Conversion to general anaesthesia was necessary in one case due to pain localised to a stiff and osteoarthritic hip. Intra-articular haemorrhage was found to be a problem in one case with synovitis. Only ten patients complained of moderate pain, none had severe pain. Local anaesthesia is contraindicated in cases with ipsilateral osteoarthritis of the hip or with significant synovitis of the knee. This technique is particularly suited to day case surgery.
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Ketogenic diets have a high fat and low carbohydrate and low protein content to induce ketosis which is monitored by daily urine testing. Lapses in diet are frequently associated with loss of anticonvulsant control. There has, as yet, been no report of children maintained on a ketogenic diet subject to anaesthesia and surgery: this paper records the changes in metabolic variables observed in three patients undergoing simple inhalation anaesthetics for minor surgery.
Plasma concentrations of adrenaline and noradrenaline were measured sequentially over the immediate post-operative period following clipping of an intracranial aneurysm in 11 patients. Those patients who developed local cerebral vasospasm showed a sustained rise in plasma catecholamines, particularly noradrenaline, whilst those patients who developed generalised cerebral vasospasm showed early peaks of very high concentrations of adrenaline and noradrenaline which preceded radiological evidence of generalized vasospam.
The effect of local nerve blockade on the relief of postoperative pain is reported in a series of 167 patients who underwent surgery of the arm, knee or foot. In 80% of cases analgesics were not required within 4 hours postoperatively, and in 39% analgesics were not required within 8 hours. Conventional methods of postoperative pain relief are not always effective. Local nerve blockade can be used to provide complete analgesia after limb surgery and is therefore of great value to postoperative care.
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Changes in plasma concentrations of adrenaline and noradrenaline were measured when sodium nitroprusside (SNP) was used for the induction of hypotension in healthy adults undergoing middle ear surgery (group 1) and patients undergoing neurosurgery for subarachnoid haemorrhage (group 2). The mean catecholamine concentrations before the infusion of SNP were four to five times greater in group 2 than in group 1. Group 1 showed significant increases in plasma catecholamines during hypotension induced with SNP, the increase correlating significantly with the degree of hypotension and the rate of infusion of SNP. Group 1 showed an increase in heart rate of about 10%, which could not be related to the catecholamine concentrations. In group 2, changes in plasma catecholamines following infusion of SNP were inconsistent. This may have been because the sympatho--adrenal medullary system was already maximally active and was unable to respond further to induced hypotension.
A 33-year-old man with chronic renal failure underwent repair of an expanding aortic aneurysm. The management of the case is described and the anaesthetic problems discussed.
Thirteen young and thirteen elderly patients undergoing elective surgery were given an anaesthetic using tubocurarine as the sole muscle relaxant. Following reversal with neostigmine, the time taken to recover from neuromuscular blockade was measured. No significant difference was found between the two groups of patients.
Plasma adrenaline and noradrenaline concentrations were measured in 21 patients after subarachnoid haemorrhage and in 13 control patients. Plasma noradrenaline concentrations were significantly raised in patients recovering from subarachnoid haemorrhage, confirming clinical evidence of overactivity of the sympathetic nervous system. Plasma noradrenaline concentrations in patients with a poor result were significantly higher at the time of admission than in patients with a good result, and the differences became more significant two to three days later. Therefore, the measurement of plasma noradrenaline concentrations may be a valuable test to assist clinical assessment in distinguishing between the two groups preoperatively.
A simple modification of a clinical blood pressure transducer is described, which permits it to be used for the quantitative estimation of neuromuscular blockade in man. The instrument remains available for other pressure measurements since only the plastic dome is modified.
Subarachnoid haemorrhage from intracranial aneurysms has a poor prognosis. Operative management of intracranial aneurysms was once considered ineffective. The first 100 cases treated by micorsurgery were analysed to see whether mortality and morbidity were reduced. Modern surgical techniques halved the total mortality but the morbidity was unaltered. Results can be improved by delaying surgery seven days and by treating any hypertension before surgery.
This paper reports a retrospective study of the microneurosurgical management of intracranial aneurysm in 133 patients. Good or fair results were obtained in 76%, 12% of patients had a poor result and the mortality was 12%. Major factors which were found to influence the outcome of surgery were: pre-operatively, the Botterell grade of the patient, pre-existing systemic hypertension and the time interval between the last subarachnoid haemorrhage and surgery. Post-operatively, the development of cerebral vasospasm was associated with a poor outcome from surgery. Better results might be obtained from the surgery of intracranial aneurysm by delaying operation to the second week after subarachnoid haemorrhage and by better management of hypertensive patients pre-operatively and patients who develop cerebral vasospasm post-operatively.
This paper reports a retrospective study of the preoperative and postoperative management of 28 patients who underwent thymectomy between 1956 and 1973. Patients who received postoperative artificial ventilation were compared with the group who did not with respect to sex, age, severity of disease, preoperative vital capacity, and thymic histology. Evidence is presented that postoperative artificial ventilation is required when the preoperative vital capacity with the patient on optimum anticholinesterase treatment is less than 2 litres. Additional features associated with a probable need for artificial ventilation were the presence of a thymoma, bulbar symptoms, especially dysphagia, and age over 50 years. These should be taken into account in any patient whose vital capacity is close to the critical level of 2 litres. When postoperative ventilation was required it was usually necessary for 12 days or more, and tracheostomy should therefore be done at or before thymectomy. Most patients in this series received the same dose of anticholinesterases after operation as before it and no evidence was found of a sudden decrease in requirements for anticholinesterase therapy. Two patients did not, and in them a myasthenic crisis was precipitated. We propose that the preoperative drug regimen can be continued in the immediate postthymectomy period, allowing selection of patients for tracheostomy and artificial ventilation primarily on the basis of the preoperative vital capacity.
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In patients with subarachnoid hemorrhage there were increased concentrations of plasma epinephrine and norepinephrine when compared with those concentrations in a group of patients admitted to hospital with other illness. Reassessment after a variable period showed that in patients whose eventual clinical result was poor the plasma epinephrine and norepinephrine concentrations increased further while in those with a good result those concentrations showed a decline. No such changes were evident in plasma dopamine-beta-hydroxylase activities which were within normal range. In a sub-group of patients who had neurosurgery after admission for clipping an aneurysm, the post-operative changes of plasma epinephrine and norepinephrine concentrations were related to the clinical condition of the patients.