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[Paracervical block for hysteroscopy in patient with spinal muscular atrophy].
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Carotid artery surgery. Local versus general anaesthesia as related to sympathetic activity and cardiovascular effects.
Arterial plasma catecholamines, blood pressure and heart rate were determined in 75 patients before, during and after carotid endarterectomy. Local anaesthesia given as a cervical block with skin infiltration containing 200 micrograms adrenaline was used in 28 patients (LA-group), general anaesthesia (nitrous oxide, fentanyl, isoflurane) with skin infiltration containing 200 micrograms adrenaline in 32 patients (GAs-group) and general anaesthesia without skin infiltration in 15 patients (GAo-group). In the LA-Group plasma noradrenaline (P-NA) levels were significantly higher during anaesthesia and surgery, with an increase from preanaesthesia levels (P less than 0.05). P-NA decreased from a preanaesthesia level in the GAo-group (P less than 0.01) but remained unaltered in the GAs-group. P-NA values in the GAo-group were lower than those of the GAs-group (P less than 0.001) following anaesthesia and surgery. Plasma adrenaline (P-A) increased in the LA- and the GAs-group and decreased in the GAo-group (P less than 0.001) following anaesthesia and surgery. In the LA-group P-A was similar before the skin incision and clamping but higher after declamping as compared to the GAs-group. Before the skin incision and thereafter P-A was lower in the GAo-group as compared to the other groups. There was a positive correlation between plasma catecholamines, on the one hand, and mean blood pressure and heart rate on the other. Two patients in the LA-, eight in the GAs- and seven in the GAo-group showed a hypotensive blood pressure reaction (SBP less than 100 mmHg; LA vs. GAo, P less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)
Resection of an internal carotid artery aneurysm under regional anesthesia: posterior cervical block.
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[Comments on the paper by G. Wald-Oboussier and B. Veill. Supraclavicular plexus blockade using prilocaine in patients with chronic anemia].
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The anatomical rationale for an upper limb sympathetic blockade: preliminary report.
Stellate ganglion blockade (SGB) has long been considered pivotal in the diagnosis, determination of prognosis and management of chronic regional pain syndrome (CRPS) by sympathectomy. To date a variety of SGB techniques have been described. An inaccurate SGB may mislead clinicians and deny patients a potentially beneficial procedure. In order to obtain a predictable and readily reproducible blockade of the upper limb, a modified anterior technique was evaluated. This modified sympathetic block was performed in 10 adult cadavers (n=19 sides). Toluidine blue solution (10 ml) was injected and, following median sternotomy, the extent of spread of dye was evaluated. In one cadaver a dual block using both the modified and the standard techniques was performed. Proximal spread to the seventh cervical vertebra was noted in all blocks; distal spread extended to the neck of the third rib (n=3), neck of the fourth rib 7 (n=15) and neck of the seventh rib (n=1). Medial spread was greater than lateral spread and extended to the vertebral bodies (vagus nerve was also stained) while lateral spread in all cases "blocked" lower roots of the brachial plexus and was consistently noted beyond the usual location of the nerve of Kuntz. This modified technique demonstrated that the lower cervical ganglia and proximal thoracic sympathetic trunk were consistently stained. It should be noted that the spread was sufficiently lateral to block the nerve of Kuntz. The pitfalls of this technique aside, we suggest that this technique be reserved for therapeutic purposes, particularly when sympathectomy is not possible.
Brachial plexus block with a new local anaesthetic: 0.5 per cent ropivacaine.
A new local anaesthetic, ropivacaine hydrochloride, was used in a concentration of 0.5 per cent in 32 patients receiving a subclavian perivascular block for upper extremity surgery. One group (n = 15) received 0.5 per cent ropivacaine without epinephrine and a second group (n = 17) received 0.5 per cent ropivacaine with epinephrine in a concentration of 1:200,000. Anaesthesia was achieved in 87 per cent of the patients in both groups in all of the C5 through T1 brachial plexus dermatomes. Motor block was profound with 100 per cent of patients in both groups developing paresis at both the shoulder and hand and 100 per cent developing paralysis at the shoulder. There was a rapid initial onset of sensory block (a mean of less than four minutes for analgesia) with a prolonged duration (a mean of greater than 13 hr of analgesia). The addition of epinephrine did not significantly affect the quality or onset of sensory or motor block. The duration of sensory block was reduced by epinephrine at T1 for analgesia and at C7, C8, and T1 for anaesthesia. The duration of sensory block in the remaining brachial plexus dermatomes as well as the duration of motor block was not effected by epinephrine. There was no evidence of cardiovascular or central nervous system toxicity in either group with a mean dose of 2.5-2.6 mg.kg-1 ropivacaine.
Fasciculation-myokymic activity and prolonged nerve conduction block. A physiopathological relationship in radiation-induced brachial plexopathy.
Fourteen radiation-induced brachial plexus neuropathies in 12 patients suffering from cancer were studied. Neurophysiological evaluation showed a diffuse neurogenic lesion with muscular denervation signs associated with motor and sensory nerve conduction impairment of axonal type in the distal segments of the arm. Somatosensory evoked potentials were frequently abnormal, with absence of N9 in 9 out of the 10 extremities explored. The most characteristic findings were, however, the presence of fasciculation potentials--single and grouped--and myokymic discharges in 78.5% of cases (11 out of 14 plexuses), and a motor nerve conduction block on proximal stimulation, at the supraclavicular as well as cervical spine levels, in all of the cases. Both phenomena showed a high correlation when analyzed in the same neuromuscular territory. The 5 muscles with no voluntary activity and complete--or nearly complete--motor nerve conduction block were the ones with the most intense ectopic activities. The conduction blocks were present after long periods of illness in all cases and, in 2 of the cases, they persisted in successive explorations at intervals of 9 months and 2 years respectively. These data would support a probable cause-effect relationship between a persistent and prolonged motor nerve conduction block and the presence of fasciculation-myokymic type activities. One could even postulate that the infrequent neuropathies, in which both findings have been described as relevant features, have a similar physiopathological mechanism.
Cervical block for carotid endarterectomy followed immediately by general anesthesia for coronary artery bypass and aortic valve replacement.
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Defining the cross-sectional anatomy important to interscalene brachial plexus block with magnetic resonance imaging.
BACKGROUND AND OBJECTIVES: Interscalene brachial plexus block is a useful technique to provide anesthesia and analgesia for the shoulder and proximal upper extremity. The initial needle direction at the interscalene groove has been described as being "perpendicular to the skin in every plane" (1). A cross-sectional (axial) approach may offer a more easily conceptualized directed needle placement. The purpose of this study is to define the cross-sectional anatomy and idealized needle angles important to interscalene brachial plexus block. METHODS: Following IRB approval, 50 patients were studied. Cross-sectional volume coil T1-weighted magnetic resonance images (MRI) were obtained from 50 patients undergoing cervical region imaging for other reasons. At the interscalene groove, a simulated needle path to contact the ventral rami or trunks of the brachial plexus was approximated at the level of C6 or C6-C7 interspace. The angle of this needle path intersecting the sagittal plane was recorded for each patient. RESULTS: The mean angle of the simulated needle path relative to sagittal plane was determined to be 61.1 +/- 6.1 degrees (range, 50-78 degrees). In 13 of 50 (26%) MRI scans, the cervical nerve roots were not visualized at the level of C6 and were measured at the C6-C7 level. CONCLUSIONS: These findings suggest initial needle placement at the interscalene groove should be angled less perpendicularly relative to the sagittal plane than is often observed. A cross-sectional approach enables more practical visualization of initial needle placement. A more accurate initial needle placement may minimize the number of needle passes necessary to contact the nerve roots, thereby more efficiently obtaining a successful block.
Postoperative blood pressure changes associated with cervical block versus general anesthesia following carotid endarterectomy.
The purpose of this report was to determine if cervical block anesthesia (CBA) was associated with fewer hypertensive and hypotensive episodes and decreased need for ICU monitoring following carotid endarterectomy, compared with general anesthesia (GA). A retrospective review of carotid endarterectomies performed using GA (n = 118) versus CBA (n = 116) was carried out and perioperative blood pressure changes and morbidity and mortality rates were analyzed. With increasing emphasis in today's health care market concerning cost containment without sacrificing safety, our results suggest that CBA should be considered preferable to GA for patients undergoing carotid endarterectomy. Fewer significant postoperative hemodynamic changes occurred and costly intensive care monitoring may be avoided.
Incidence, timing, and causes of cerebral ischemia during carotid endarterectomy with regional anesthesia.
PURPOSE: Controversy exists regarding the best technique to identify cerebral ischemia during carotid endarterectomy (CEA). Regional anesthesia allows continuous evaluation of neurologic function and therefore can help determine the incidence, timing, and causes of cerebral ischemia. METHODS: The timing and clinical manifestations of any neurologic event during CEA and as long as 30 days afterward was determined by review of operative reports, hospital charts, and outpatient records of consecutive patients who underwent CEA under regional anesthesia over a 68-month period. RESULTS: Two hundred patients underwent CEA; indications were asymptomatic stenosis > 60% in 25%, transient ischemic attack with stenosis > 50% in 52%, and prior stroke with stenosis > 50% in 23%. Eight patients (4%) were converted to general anesthesia for non-ischemic reasons. Of the remaining 192 patients, 183 (95.5%) underwent the procedure with regional anesthesia and no shunt, 2% had cerebral ischemia and underwent shunt placement, and 2.5% had cerebral ischemia, were converted to general anesthesia, and underwent shunt placement. Cerebral ischemia developed in nine patients after carotid cross-clamping, manifested by loss of consciousness in four, confusion in two, dysarthria and confusion in one, and decreased contralateral motor strength in two. Immediate cerebral ischemia developed in four of the nine patients within 1 minute of cross-damping; all four underwent shunt placement. In five of the nine patients, cerebral ischemia occurred between 20 and 30 minutes after cross-clamping; all occurred during relative intraoperative hypotension (average reduction of 35 mm Hg in the systolic pressure). All awake patients in whom ischemic symptoms developed immediately regained and maintained normal neurologic function with shunt placement. Five of 26 patients (19%) with contralateral occlusion required a shunt; none had postoperative ischemia. The mean carotid cross-clamp time was 27 minutes. Postoperative (30 day) complications included a 0.5% stroke rate, a 0.5% rate of postoperative transient ischemic attack, a 0.5% rate of worsening of preexisting acute stroke, and a 0.5% rate of myocardial infarction (no deaths). Of the nine patients who had intraoperative ischemic changes, none had a postoperative neurologic deficit; the three patients who had postoperative neurologic changes had no intraoperative ischemic symptoms. CONCLUSIONS: CEA with regional anesthesia allows continuous neurologic monitoring and can be performed safely even when contralateral occlusion coexists; intraoperative shunting for ischemia is necessary in 4.5% of all cases and in 19% of patients with contralateral occlusion. Intraoperative ischemia was flow-related in our patients; it occurred early from ipsilateral carotid clamping and late from reduced collateral flow as a result of hypotension. Monitoring should be continued throughout cross-clamping to identify late cerebral ischemia. Postoperative cerebral ischemia is not associated with intraoperative ischemia, if corrected.
Selective shunting on the basis of carotid clamping under regional anesthesia.
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[Local anesthesia technics for dental treatment by quadrants].
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[Brachial plexus block by the supraclavicular approach].
The work based upon the investigation of the brachial plexus in 25 corpses proposes to fulfil the blockade of the brachial plexus by the introduction of the needle into the area of forming the upper primary trunk. The advantages of the method proposed are a relative technical simplicity and a considerably little danger to injure large blood vessels of the neck and cervical plexus.
Interscalenic approach to the cervico-brachial plexus.
The concept of a closed peri-neurovascular space surrounding the cervicobrachial plexus, introduced by A. Winnie, allows the blockade of the cervical and brachial plexuses by means of a single puncture technique. The single puncture has positive advantages: 1. The rapidity of the blockade; 2. The simplicity of the blockade; 3. Comfort for the patient. The landmarks are easy to make. As with epidural blockade, the injection level and the volume of local anesthetic determine the quality and extent of the block. The traditional indication is surgery of the shoulder and of the supraclavicular area. A new indication seems to be the implantation of a cardiac pacemaker. Complications often quoted in literature are Horner syndrome-a minor complication-and blockade of the ascending branches of the recurrent laryngeal nerve and of the phrenic nerve. The risk of a pneumothorax is almost nil.
Functional relation of the paracervical nerve plexus to the progress of experimentally induced cervical carcinoma of the uterus.
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Pulmonary function changes during interscalene brachial plexus block: effects of decreasing local anesthetic injection volume.
BACKGROUND AND OBJECTIVES: During interscalene block, ipsilateral hemidiaphragmatic paresis occurred in all patients who received > 34 ml of local anesthetic in the authors' previous studies. This study was done to determine whether diaphragmatic function could be spared by a smaller local anesthetic volume. METHODS: Twenty patients were randomly assigned to receive either a 45 ml or 20 ml interscalene brachial plexus block. For all blocks, 1.5% mepivacaine with added epinephrine and bicarbonate was used. Baseline serial measurements and those over a 30-minute test period before surgery were analyzed for significant differences between groups in onset or final change in any of the following measured variables: cephalad dermatomal extent of sensory anesthesia, clinically assessed upper extremity motor function, ipsilateral hemidiaphragmatic excursion during maximal sniff (inspiratory), and pulmonary function. RESULTS: There were no clinically significant differences between groups in any of the measured variables. Large reductions in routine pulmonary function tests were measured in all patients in both groups at 2 minutes after injection. At 30 minutes, baseline forced vital capacity (FVC) had diminished by 40.9 +/- 11.7% in the 45 ml group and 32.0 +/- 8.9% in the 20 ml group. One patient with pre-existing chronic obstructive pulmonary disease had a decrease in FVC from 1.83 l to 0.59 l, a 68% decrement from the baseline measurement, both measured in the supine position. CONCLUSION: Reducing the volume of local anesthetic to 20 ml did not prevent the 100% incidence of diaphragmatic paresis or significantly lessen the compromise in pulmonary function that had been reported to occur during interscalene brachial plexus anesthesia.