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Biomedical subjects

Y Shir

Publications and source records attributed to Y Shir.

At least 37 records · Page 2Linked to original sources
PubMed1996

Anaesthetic management of a patient with glycogen storage disease type 1b.

PURPOSE: A rare case of a ten-year old patient with type 1b glycogen storage disease (GSD), scheduled for extracorporeal shockwave lithotripsy (ESWL), is described. CLINICAL FEATURES: Patients with type 1b GSD manifest a range of clinical symptoms, including mental retardation, hepatosplenomegaly, renal enlargement, stomatitis, hypoglycaemic convulsions, bleeding diathesis, lactic acidosis and leukopaenia, thus creating a challenge for the anaesthetist. Following preanaesthetic administration of glucose-containing fluids, general anaesthesia was induced and the patient was mechanically ventilated. Except for mild hypoglycaemia after induction of anaesthesia, and moderate intraoperative metabolic acidosis which was attributed to the underlying disorder, anaesthesia was uneventful. No postoperative complications occurred and the patient was discharged home three days after lithotripsy. Clinical features of this rare inborn error of metabolism are reviewed and the approach for the anaesthetic management is discussed. CONCLUSIONS: A skillful perioperative management of patients with type 1b GSD can be achieved by cautious attention to the metabolic and homeostatic derangements that occur with the disease.

Anesthesia↗
PubMed1995

[Endobronchial stenting in bronchial stenosis following lung transplantation].

Endobronchial stricture is not an uncommon complication following lung transplantation and may cause significant morbidity and mortality. We report our experience in a 36-year-old woman and a 39-year-old man who underwent lung transplantation and developed stenosis in the anastomotic area. Implantation of a silicone stent in 1 patient and an expandable metal stent in the other were successful. Both patients developed infections with Aspergillus fumigatus, 1 of whom died of fungal dissemination.

Adult↗
PubMed1995

Intraoperative blood loss during radical retropubic prostatectomy: epidural versus general anesthesia.

OBJECTIVES: There are conflicting reports on the influence of different anesthetic techniques, such as regional versus general anesthesia, on intraoperative blood loss. The purpose of this study was to elucidate the effects of anesthetic technique on intraoperative blood loss in men undergoing radical retropubic prostatectomy (RRP). METHODS: One hundred patients undergoing RRP for prostate cancer were randomly assigned to receive either epidural anesthesia (EA), combined epidural and general anesthesia (EG), or general anesthesia alone (GA). Intraoperative blood loss was calculated by using a formula that accounted for the volume and hematocrit of the fluid suctioned from the surgical field, blood absorbed on surgical pads, and the patient's hematocrit. RESULTS: Mean blood loss in the EA group (1490 +/- 90 mL; mean +/- SEM) was significantly less than mean blood loss in both the EG group (1810 +/- 100 mL) and the GA group (1940 +/- 130 mL) (P = 0.01). Blood loss was not different between the EG and the GA groups (P = 0.7). Significantly less blood was transfused during surgery in the EA group (730 +/- 50 mL) compared with the EG (960 +/- 60 mL) and GA (950 +/- 70 mL) groups (P = 0.02). CONCLUSIONS: Similar blood loss in patients receiving general anesthesia, either alone or when combined with epidural anesthesia, implies that epidural anesthesia did not reduce bleeding, but, rather, that general anesthesia increased blood loss.

Anesthesia, Epidural↗
PubMed1994

Postoperative morbidity is similar in patients anesthetized with epidural and general anesthesia for radical prostatectomy.

OBJECTIVES: To compare the effect of epidural and general anesthesia on the postoperative course and complication rate in patients undergoing radical prostatectomy. METHODS: Ninety-eight men scheduled for radical retropubic prostatectomy (RRP) were randomly assigned to receive epidural anesthesia only (EA, n = 34), combined epidural and general anesthesia (EG, n = 33) or general anesthesia only (GA, n = 31). In the EA group, epidural anesthesia was induced and maintained with bupivacaine. In the EG group, patients received epidural bupivacaine after the induction of general anesthesia. In the GA group, anesthesia was induced with morphine and maintained with isoflurane. In the postoperative period, epidural patient-controlled analgesia (PCA) was maintained in all patients for 3 to 5 days. Patients were evaluated throughout the hospitalization period and at 3, 6, and 12 weeks following surgery. RESULTS: The three groups did not differ with regard to postoperative pain, bleeding, urine output, fever, length of paralytic ileus, or length of hospitalization. No major cardiovascular, pulmonary, or neurologic complications occurred in any of the patients either perioperatively or in the first 3 months postoperatively. CONCLUSIONS: Intraoperative anesthetic technique was not associated with a different postoperative complication rate in patients undergoing RRP. The very low incidence of complications and the uniform postoperative analgesic regimen may have contributed to the similarity between groups.

Analgesia, Patient-Controlled↗
PubMed1994

The effect of epidural versus general anesthesia on postoperative pain and analgesic requirements in patients undergoing radical prostatectomy.

BACKGROUND: Although preemptive analgesia has been shown to decrease postinjury pain in animals, studies in humans have provided controversial results. The authors studied whether surgical epidural anesthesia with local anesthetics could affect postoperative pain and analgesic demands, when compared with general anesthesia. METHODS: Male patients scheduled for radical retropubic prostatectomy were randomly assigned to receive epidural anesthesia only (EA, n = 34), combined epidural and general anesthesia (EG, n = 32), or general anesthesia only (GA, n = 30). A lumbar epidural catheter was inserted and tested in all patients. In the EA group, an induction dose of 0.25 ml/kg epidural bupivacaine (0.5%) was followed during surgery by a continuous infusion of 0.1 ml.kg-1.h-1 0.125% bupivacaine. In the EG group, 0.2 ml/kg epidural bupivacaine (0.5%) was injected after induction of general anesthesia but before surgery, followed by epidural infusion of 0.1 ml.kg-1.h-1 0.125% bupivacaine. In the GA group, anesthesia was maintained with morphine, isoflurane, and N2O. Epidural patient-controlled analgesia (PCA) was provided with bupivacaine and fentanyl for all patients in the postoperative period. Postoperative pain scores and analgesic requirements were examined and compared between groups every 4-8 h for 3-5 postoperative days. RESULTS: Intraoperatively, EA patients received significantly more epidural bupivacaine than EG patients (129 +/- 6 mg vs. 98 +/- 6 mg, respectively. Recovery room median residual sensory level in EA patients (T6 +/- 2) was significantly higher than in EG patients (T10 +/- 2). PCA demand was greater in the GA and EG groups when compared with the EA group in postoperative days 2 (126 +/- 9 ml, 112 +/- 9 ml, 90 +/- 6 ml, respectively; P = 0.01) and 3 (89 +/- 10 ml, 83 +/- 9 ml, 48 +/- 5 respectively; P = 0.005). There was no difference in PCA demand between the GA and EG groups in the postoperative period. No significant clinical differences in postoperative mean pain scores were recorded in the first 5 days after surgery in the three anesthetic groups (range 0-2/10). CONCLUSIONS: In patients undergoing lower abdominal surgery, the neuraxial blockade and surgical anesthesia achieved by epidural local anesthetics was associated with decreased postoperative analgesic demands. Lower postoperative analgesic requirements in the EA group, when compared with both the EG and GA groups, indicate that: (1) EA patients had less postoperative pain, and (2) an efficient intraoperative blockade of noxious afferent signals to the central nervous system is fundamental in reducing postoperative pain.

Analgesia, Patient-Controlled↗
PubMed1994

Core hypothermia and skin-surface temperature gradients. Epidural versus general anesthesia and the effects of age.

BACKGROUND: Inadvertent hypothermia occurs frequently during surgery and may be associated with adverse outcomes. Although various anesthetic agents have been shown to impair thermoregulation, the impairment with regional and general anesthetics has not been directly compared. METHODS: Thirty patients undergoing radical retropubic prostatectomy were randomly allocated to receive epidural (EA, n = 15) or general (GA, n = 15) anesthesia. Tympanic membrane measurements were used to assess core temperature. Forearm and calf skin-surface temperature gradients were used to assess thermoregulatory vasoconstriction (forearm minus fingertip > 4 degrees C and calf minus toe > 6 degrees C). The two groups were compared during the intraoperative and early postoperative periods to identify differences. Subgroup analysis was used to compare core temperatures and skin-surface gradients in younger (< 62 yr of age) and older (> or = 62 yr) patients in the EA and GA groups. RESULTS: Mean tympanic membrane temperatures were similar at all time periods in the EA and GA groups and were nearly identical at the end of the surgical procedure (EA, 35.5 +/- 0.2 degrees C; GA, 35.6 +/- 0.2 degrees C) (P = 0.68). Intraoperatively, the EA group maintained a significant forearm skin-surface gradient compared to the GA group (P = 0.0001), whereas the calf gradients were minimal and were similar between groups. Postoperatively, both groups had comparable positive forearm gradients, whereas calf gradients were greater in the GA group (P = 0.001). Mean core temperatures and forearm gradients were not different between the younger and older patients receiving GA. In those receiving EA, the younger patients had greater mean core temperatures (P = 0.015) and greater forearm gradients (P = 0.05) for most of the perioperative period. CONCLUSIONS: The EA and GA groups had virtually identical core temperature profiles during the intraoperative and post-operative periods. Comparison of skin-surface gradients suggests that EA is associated with less intraoperative upper-body thermoregulatory impairment but greater and persistent post-operative lower-body impairment. During EA, younger patients appeared to maintain thermoregulatory activity relative to the older patients. In patients receiving GA, the age-related differences were minimal.

Aged↗
PubMed1994

Cardiac sympathovagal balance and peripheral sympathetic vasoconstriction: epidural versus general anesthesia.

Both epidural and general anesthetics alter autonomic balance. However, the relative differences between epidural (EA) and general anesthetics (GA) with regard to cardiac and peripheral sympathovagal balance have not been described. Twenty consecutive patients scheduled for radical retropubic prostatectomy were randomized to receive EA (n = 10) or GA (n = 10). Power spectral analysis was performed on the electrocardiographic recordings, with the ratio of low (0.05-0.125 Hz)/high (0.125-0.5 Hz) frequency power used an index of cardiac sympathovagal balance. The forearm minus fingertip skin-surface temperature gradient (> 4 degrees C) was used as an indicator of sympathetically mediated peripheral vasoconstriction. Patients in the EA group demonstrated a significantly greater low/high frequency power ratio and a more frequent incidence of peripheral vasoconstriction than the GA group during the intraoperative period. During the postoperative period, the GA group demonstrated an increase in the low/high ratio and the incidence of vasoconstriction relative to the intraoperative period. Intraoperatively, upper body vasoconstriction appears to be accompanied by a significant shift in cardiac sympathovagal balance toward sympathetic predominance with EA relative to GA. Postoperatively, GA is associated with a shift in the sympathovagal balance toward sympathetic predominance. Further research is required to determine whether this results in cardiovascular compromise in the high-risk patient.

Anesthesia, Epidural↗
PubMed1993

The safety of intravenous phentolamine administration in patients with neuropathic pain.

The safety of intravenous (i.v.) infusion of large doses of phentolamine as an outpatient diagnostic tool for sympathetically maintained pain was studied retrospectively in 100 consecutive patients (73 females and 27 males) with chronic pain. All patients were pretreated with i.v. fluids followed, in most cases, by propranolol, 1-2 mg i.v. (n = 95). Ten minutes later the phentolamine infusion commenced, lasting for 20 min. In 90 patients, the dose of phentolamine was 35 mg. Two patients received 25 mg, and 8 patients received larger doses of 50-75 mg. No major complications occurred during or after the test, and only small changes in arterial blood pressure or heart rate were observed. All patients developed mild nasal stuffiness, but no decline in oxygen saturation was observed. Five patients developed one of the following minor complications for a brief duration, that resolved spontaneously: sinus tachycardia, premature ventricular beats, dizziness, or wheezing. We conclude that i.v. phentolamine administration is safe in patients with neuropathic pain.

Age Factors↗
PubMed1991

Mechano- and thermo-sensitivity in rats genetically prone to developing neuropathic pain.

By selective breeding, lines of rats were derived which consistently expressed high (HA) or low (LA) levels of autotomy following sciatic nerve injury, autotomy being a behavior pattern presumed to reflect the presence of neuropathic paraesthesias and pain. We report here that intact (unoperated) HA and LA rats differ in their responsiveness to cutaneous mechanical and thermal stimuli. Thus, the autotomy trait, which was identified by its expression under conditions of nerve injury, shares determinants with sensory processing channels in the intact animal.

Animals↗
PubMed1991

Continuous epidural methadone treatment for cancer pain.

Seventy cancer patients suffering from visceral or somatic pain received continuous epidural methadone (EM) analgesia. Initially, 4 mg of 0.1% methadone was given three times daily. If this dose proved ineffective, it was gradually increased to 8 mg four times daily. With this regimen good pain control was obtained in 56 patients (80%). Patients continued the EM therapy for periods up to 140 days, with an average duration of 27 days. Morphine was substituted for methadone in 14 patients (20%). Four of these patients responded well and continued treatment for an average of 18 days. No serious side effects have been observed with EM. With a proper selection of patients and following strict therapy guidelines, epidural methadone is efficacious in treating cancer pain.

Adolescent↗
PubMed1990

[Surgical pulmonary embolectomy and thrombolytic therapy].

Acute, massive pulmonary embolism is life-threatening and must be treated immediately. Since the early 1970's when thrombolytic therapy was shown to hasten resolution of pulmonary emboli, there has been a debate in the literature as to new indications for surgical pulmonary embolectomy. Some authors believed that there are no longer any indications for embolectomy, while others justify surgery for certain indications. Although the debate is still on, this operation is very rarely performed today. We present a patient who developed massive pulmonary embolism, with continuing extreme hemodynamic and respiratory disturbances despite full thrombolytic treatment. Embolectomy was successfully performed.

Female↗
PubMed1990

A-fibers mediate mechanical hyperesthesia and allodynia and C-fibers mediate thermal hyperalgesia in a new model of causalgiform pain disorders in rats.

Unilateral tight ligation of about half of the sciatic nerve in rats rapidly produces sympathetically dependent neuropathic pain which lasts many months and resembles causalgia in humans. The sensory abnormalities detected at the plantar side of the hindpaws include: (1) nocifensive responses to repetitive light touch (allodynia); (2) bilateral reduction in withdrawal thresholds to repetitive von-Frey hair stimulation (mechanical hyperesthesia); (3) bilateral reduction in withdrawal thresholds to CO2 laser heat pulses; and (4) unilateral increase in response duration to an intense laser heat pulse (thermal hyperalgesia). Using neonatal capsaicin treatment, we determined the type of afferent fiber remaining in the partially injured nerve, which mediates these disorders. Capsaicin, which destroys most C- and some A delta-fibers in peripheral nerves, had no effect on the touch-evoked allodynia and mechanical hyperesthesia that are produced by partial sciatic nerve injury. These disorders were, therefore, mediated by myelinated fibers. In contrast, thermal hyperalgesia failed to develop in capsaicin-treated rats following partial nerve injury. Thus, thermal hyperalgesia produced by partial nerve injury appears to be mediated by heat-nociceptive C-fibers.

Afferent Pathways↗
PubMed1990

[Neuropathic pain unrelieved by morphine, alleviated by haloperidol].

Neuropathic pain, originating in damaged nerve and not peripheral nociceptors, is often resistant to treatment by opiates given by the oral, parenteral or spinal routes. This failure to obtain satisfactory pain relief is generally ascribed to psychological factors or to individual peculiarities in drug metabolism or kinetics. Currently, psychotropic and antidepressant drugs are among the first choices in treating painful conditions due to partial nerve lesions. We present a 56-year-old man who suffered intractable pain confined to his left knee following emergency L2-3 vertebral decompression, after collapse due to metastatic disease. 12 mg of morphine and 10 of diazepam given together intravenously did not lessen pain. Acute, solitary spinal nerve root injury was hypothesized. 2 mg of haloperidol injected IV gave complete relief of pain without hypotension or deep sedation. There is no definite explanation for the resistance of neuropathic pain to opiates.

Haloperidol↗
PubMed1990

Plasma concentrations of methadone during postoperative patient-controlled extradural analgesia.

Plasma concentrations of methadone were measured by gas chromatography in 16 patients receiving extradural methadone by continuous infusion for relief of postoperative pain. Venous blood samples were taken after a loading dose of extradural methadone 2 mg and during infusion of 0.46 mg h-1 plus patient-controlled increments of 0.2-1 mg. Mean (SD) plasma concentration of methadone was 9.8 (2.1) ng ml-1 at 15 min; this did not change significantly during the first 2 h, after which it increased gradually to 32.2 (4.6) ng ml-1 (P less than 0.001) at the end of 24 h. The mean quantity of extradural methadone required to produce effective analgesia was 10.3 (1.8) mg during the first 12 h after operation and 6 (1.0) mg for the subsequent 12 h. The mean amount of methadone for effective analgesia on the second day was 7.6 (1.1) mg. No adverse effects were detected during the 2-3 days of methadone therapy. Plasma concentration of methadone increased significantly during patient-controlled infusion of extradural methadone in the first 24 h after operation, suggesting rapid vascular uptake. Systemic activity of the drug contributes to the analgesic effect of extradural methadone.

Adult↗
PubMed1989

[Continuous intercostal nerve block for chronic pain].

21 ambulatory patients with acute or chronic pain localized to the chest, were treated successfully by continuous intercostal block. They included 6 women and 15 men, aged 39-70. Treatment was initiated in the outpatient clinic and continued at home for usually 5-6 days. Between 15-20 ml of 0.5% marcaine were continuously injected over the course of 6-12 hours through a catheter introduced into the intercostal space by a Touhy needle. 76% of the patients had substantial relief of pain during the block and required only minimal systemic medication. During a 3 month follow-up after cessation of the block, up to 65% were still pain-free. Results were poor or only fair in those with malignancy and long-standing intercostal neuralgias. There were no serious side-effects during treatment. This method is an important new tool in the treatment of pain.

Acute Disease↗