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PubMed1998

General anesthesia for cesarean section at a tertiary care hospital 1990-1995: indications and implications.

Complications of general anesthesia for cesarean section remain the leading cause of anesthesia-related maternal mortality. General anesthesia, however, is becoming less popular for obstetric anesthesia, and thus fewer cesarean sections are conducted using this technique. As the number of general anesthesia cases decrease, the number of difficult intubations witnessed and managed by residents decreases. In addition, patients who undergo general anesthesia may have co-morbidities which, while not contraindicating regional anesthesia, may increase the risk of providing anesthesia. We reviewed the medical records of 6 calendar years (1990-1995) at our busy tertiary center, to determine patient demographics, indications for cesarean section, indications for general anesthesia, time of day, and complications related to airway management. From 1990 through 1995, cesarean sections under general anesthesia decreased from 7.2% to 3.6% (P=0.0001), however, they were performed on parturients with more maternal diseases (17.2% to 35.8%; P=0.0034). Although the incidence of difficult intubations in those years ranged from 16.3% to 1.3%, only one failed intubation with resultant maternal mortality occurred. Few residency programs offer instruction on the difficult airway in the parturient population. Organized airway management programs specifically for the obstetric population may assist efforts to decrease the morbidity and mortality associated with the provision of general anesthesia for cesarean section.

Journal Article↗
PubMedDate not supplied

Converting from general anesthesia to cervical block anesthesia for carotid endarterectomy.

Between January 1, 1992 and June 30, 1998, vascular and general surgery residents performed 401 carotid endarterectomies (185 cervical block, 216 general anesthesia) under supervision of vascular attending surgeons. In January 1995, cervical block anesthesia was newly instituted. Initially anesthesiologists were randomly assigned to these cases and anesthetic technique was not standardized. At the surgeons' insistence later in the series, three specially trained anesthesiologists routinely administered cervical block anesthesia. As experience grew, surgeons realized that operating time greater than 2 hours and high neck dissections requiring mandibular retraction were poorly tolerated by cervical block anesthesia patients but that repeat carotid endarterectomies could be safely performed. Shunts were selectively inserted if significant electroencephalographic changes occurred or carotid stump pressures were less than 50 mm Hg systolic when general anesthesia was used; neurologic changes occurred when cervical block anesthesia was used; or there was a history of ipsilateral stroke for either anesthetic method. Despite an initial learning curve with cervical block anesthesia, the stroke-mortality rate was similar between the two groups (general anesthesia: 1.9% [four cerebrovascular accidents, two deaths]; cervical block anesthesia: 1.6% [two cerebrovascular accidents, two deaths]). Eight (12%) of the first 66 cervical block anesthesia patients were converted to general anesthesia compared to 2 (1.7%) of the most recent 119 patients with cervical block anesthesia (p = 0.03). After cervical block anesthesia was initiated, seven of the first eight repeat carotid endarterectomies were performed using general anesthesia compared to one of the most recent six repeat cases (p = 0.02). As surgeons' comfort with cervical block anesthesia increased, 94% (100) of the most recent consecutive 106 carotid endarterectomies were performed using this technique. These results suggest that carotid endarterectomy can be performed as safely using cervical block anesthesia as general anesthesia, specialized anesthesiologists are essential to achieve a successful outcome, selected repeat carotid endarterectomies can be performed using cervical block anesthesia, very cephalad lesions are best treated using general anesthesia, and surgical trainees can safely perform carotid endarterectomy under attending surgeon supervision if the operation is carried out expeditiously.

Anesthesia, General↗
PubMedDate not supplied

Regional techniques as an adjunct to general anesthesia for pediatric extremity and spine surgery.

The purpose of this review is to evaluate the safety of regional anesthesia techniques performed for postoperative analgesia in anesthetized children. Pediatric regional anesthesia techniques, such as nerve blocks and neuraxial injections of either local anesthetics or narcotics, can potentially reduce postoperative pain for all children undergoing surgery. However, children may react differently to anesthesia than adults, and they usually cannot tolerate the administration of regional anesthesia unless they are under general anesthesia. During a 5-year period (1999-2004) at the Shriners Hospitals for Children Northern California, 2236 regional anesthetic procedures were performed in 1809 patients. All of the regional procedures were performed with patients under general anesthesia. Ninety-one percent (1641) of patients were for orthopaedic extremity or spine surgeries. Patients ranged from 2 months to 20 years old, with 65% (1169) between the ages of 6 months and 12 years. One thousand eleven procedures were lower extremity blocks, 646 were upper extremity blocks, and 579 were neuraxial injections. Four hundred fifty-four peripheral nerve blocks were performed in patients aged 3 years or younger. Two self-limiting complications possibly related to peripheral nerve blocks were noted. No complications were noted in patients who received neuraxial injections. This retrospective review indicates that regional anesthesia techniques performed 'under general anesthesia have a low rate of complications in children. A prospective trial is recommended to establish the efficacy and safety of this practice.

Adolescent↗
PubMed1996

Control of blood pressure and heart rate in patients randomized to epidural or general anesthesia for lower extremity vascular surgery. Perioperative Ischemia Randomized Anesthesia Trial (PIRAT) Study Group.

STUDY OBJECTIVE: To examine the degree of success at maintaining patients randomized to epidural or general anesthesia for peripheral vascular surgery within predetermined blood pressure (BP) and heart rate (HR) limits. To investigate associations between such hemodynamic control and intraoperative myocardial ischemia and postoperative major cardiac morbidity. DESIGN: Prospective randomized clinical trial. SETTING: University-affiliated hospital. PATIENTS: 100 patients undergoing elective lower extremity revascularization for atherosclerotic peripheral vascular disease. INTERVENTIONS: Patients were randomized to receive either epidural anesthesia or general anesthesia. Blood pressure and HR limits were determined prior to randomization. Hemodynamic monitoring and management of anesthesia was standardized. Myocardial ischemia and major cardiac morbidity were diagnosed by a blinded cardiologist, based on continuous ambulatory ECG monitoring, cardiac enzymes, and 12 lead ECGs. Intraoperative BP and HR date were analyzed by investigators masked to the type of anesthesia given. MEASUREMENTS AND MAIN RESULTS: A greater percentage of patients randomized to general anesthesia had intraoperative BPs more above their limit (95% vs 72%, p = 0.002) and/or more rapid changes in HR (75% vs 48%, p = 0.008) or BP (100% vs 93%, p = 0.04) than those randomized to epidural anesthesia. Intraoperative ischemia and major cardiac morbidity were similar in the two anesthesia groups. Patients experiencing intraoperative ischemia, regardless of anesthetic type, more frequently had BPs greater than 10% above their upper limit (90% vs 60% p = 0.04) and/or more rapid HR changes (90% vs 58%, p = 0.03) compared with patients without ischemia. These vital sign abnormalities, however, were not necessarily temporally related to the ischemic episodes. Patients experiencing subsequent major cardiac morbidity were not different from other patients with respect to excursions out of BP on HR limits. CONCLUSIONS: Prevention of elevated intraoperative BP and/on rapid changes in BP or HR may be more successful with epidural than with general anesthesia. Such vital sign abnormalities may occur more frequently in patients who have had intraoperative ischemia or are at risk for having it later in the procedure.

Aged↗
PubMed1993

Interscalene block for shoulder arthroscopy: comparison with general anesthesia.

Arthroscopic shoulder surgery can be performed under regional or general anesthesia. The objective of this study was to demonstrate that regional anesthesia has several benefits over general anesthesia for this type of surgery, particularly in the ambulatory patient. Forty patients received general anesthesia and 63 an interscalene block. The regional block was found to be safe and effective, with a high degree of patient acceptance. It provided excellent intraoperative analgesia and muscle relaxation. Postoperatively, regional anesthesia resulted in fewer side effects, fewer hospital admissions, and a shorter hospital stay than did general anesthesia.

Adolescent↗
PubMed1997

Midazolam premedication increases sedation but does not prolong discharge times after brief outpatient general anesthesia for laparoscopic tubal sterilization.

Preoperatively administered midazolam may contribute to postoperative sedation and delayed recovery from brief outpatient general anesthesia, particularly in patients who receive significant postoperative opioid analgesics. We evaluated the effects of midazolam premedication (0.04 mg/kg) on postoperative sedation and recovery times after laparoscopic tubal sterilization (Falope rings) in 30 healthy women in a randomized, double-blind, placebo-controlled study. Patients received midazolam or saline-placebo intravenously 10 min before anesthesia. General anesthesia was induced with fentanyl, propofol, and mivacurium and was maintained with N2O and isoflurane. Sedation was quantified before and after premedication and 15, 30, and 60 min after emergence from anesthesia, using the digit-symbol substitution (DSST) and Trieger dot (TDT) tests. Management of postoperative pain and nausea and discharge criteria were standardized. Groups were similar with respect to age, weight, and duration of surgery and anesthesia. Midazolam was associated with impairment of performance on the TDT and DSST after premedication administration and 15 (TDT and DSST) and 30 (DSST) min after postanesthesia care unit (PACU) arrival. There were no differences in PACU time and time to discharge-readiness. In conclusion, midazolam premedication augments postoperative sedation in this population but does not prolong recovery times.

Adult↗
PubMed2001

The addition of interscalene block to general anesthesia for patients undergoing open shoulder procedures.

Several studies have demonstrated that interscalene brachial plexus anesthesia alone decreases postoperative pain, nausea, vomiting, urinary retention, and unplanned hospital admissions compared with general anesthesia alone. Anecdotal evidence suggests that an interscalene block combined with general anesthesia decreases unwanted effects of general anesthesia following open shoulder surgery. We compared the effect of combined interscalene block and general anesthesia with general anesthesia alone on Aldrete scores, length of postanesthesia care unit (PACU) stay, verbal rating scale (VRS) pain scores, incidence of postoperative narcotic administration and nausea, and patient satisfaction in a convenience sample of 52 men and women, ASA physical status I, II, or III. Group 1 received standard general anesthesia alone. Group 2 received an interscalene block in combination with general anesthesia using a standard technique. Group 2 had significantly lower VRS scores than group 1 while in the PACU, on the day of surgery, and on postoperative days 1 and 2. Overall satisfaction with the anesthetic technique was higher in the group 2 than in group 1. Results suggest that adding an interscalene block to general anesthesia can be of value in today's outpatient-dominated surgery schedule.

Adult↗
PubMed2001

Spinal versus general anesthesia for elective cesarean delivery: a prospective comparative study.

OBJECTIVE: To study the efficacy and safety of spinal anesthesia for elective cesarean section as compared with general anesthesia. PATIENTS AND METHODS: 175 women undergoing elective cesarean section were studied prospectively. They were allocated into two groups; the first group (n=60) received spinal anesthesia, and the second one (n=115) received general anesthesia for elective cesarean section. Preoperative and intraoperative BP and IV fluids were recorded. Chi-Square and Fisher's exact tests were used to compare differences between the two groups; p < 0.05 was considered significant. RESULTS: There were no differences between the two groups in terms of demographics, indication for elective cesarean section, operative time, gestational age, 1 and 5-min Apgar scores, and the means of preoperative and postoperative systolic and diastolic BP. A statistically significant increase was observed in terms of hypotension, postoperative analgesia, pre-induction and intraoperative IV fluids in the spinal group as compared to the general anesthesia group (p < 0.001, p < 0.01, and p < 0.01, respectively). CONCLUSION: Spinal anesthesia is as effective as a general anesthesia. Maternal and fetal outcome are favorable. Maternal hypotension can be managed successfully with modest doses of ephedrine and IV fluid infusions. It provides sufficient postoperative analgesia allowing the mother to have more vitality and comfort than those who receive general anesthesia.

Adult↗
PubMed1983

One hundred consecutive carotid reconstructions: local versus general anesthesia.

One hundred consecutive patients who underwent carotid reconstructions were divided into two groups by anesthesia type (general 46, local 54) and retrospectively reviewed. Particular interest was paid to length of hospital stay and billing data. There were no differences in presenting symptoms, risk factors, incidence of stroke, cranial nerve injury, or wound hematoma. Significant reductions in length of operating time, intensive care unit time, and postoperative stay and intraluminal shunt usage were demonstrated. Calculated billings and actual billings were reviewed and found to be markedly diminished in the local anesthesia group.

Anesthesia, General↗
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↗
PubMedDate not supplied

Spontaneous orbital hemorrhage during general anesthesia and arthroplasty.

A 72-year-old woman who had a history of arthritis and cerebral vascular accident 4 years earlier underwent hand surgery. Because regional anesthesia was not successful, general anesthesia was administered. Shortly before extubation, proptosis developed in her left eye, and she was unable to open it. The condition was due to spontaneous orbital hemorrhage and resolved with conservative treatment.

Aged↗
PubMed2006

[Ilioinguinal nerve block during general anesthesia for inguinal herniorrhaphy in adult anticoagulated patients].

Two adult anticoagulated patients after valve replacement were scheduled for inguinal herniorrhaphy. For inguinal herniorrhaphy in adults, spinal anesthesia is a common anesthetic method. In order to avoid spinal hematoma due to spinal anesthesia, however, we employed general anesthesia combined with ilioinguinal nerve block. Following induction of anesthesia, a laryngeal mask airway was inserted. Ilioinguinal nerve block was performed with 0.25% bupivacaine 20ml. Ilioinguinal nerve block was effective for maintaining hemodynamic stability throughout the operation, and decreased postoperative pain. This technique appears to be a simple and safe method for providing effective and long-lasting perioperative analgesia following inguinal herniorrhaphy in adult patients.

Aged↗
PubMed1989

Auditory perception during general anesthesia: psychologic consequences.

Since the introduction of general anesthesia in the middle of the 19th century, incidents of auditory perception during general anesthesia have been reported in the medical literature. Most of these reports have dealt with purely medical issues, and surprisingly little has been written on the psychologic sequelae of these instances of auditory perception. We discuss the possible psychologic consequences of such perception, and suggest methods of treatment and prevention of the negative aspects of auditory perception during general anesthesia.

Aged↗