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PubMed1992

[Subdural intra-arachnoid spread of local anesthetics. A complication of spinal anesthesia].

Accidental subdural injections and catheterisations are a complication of epidural and spinal anaesthesia. The incidence of subdural spread in myelographies is estimated to be over 10% by the spinal technique. With spinaloscopy in an anatomic human model, we analysed the puncture process and the influence of different needle types on the incidence of subdural injection. We compared 22-gauge Sprotte, Quincke, and 18-gauge Tuohy needles in median and paramedian approaches with various bevel orientations. METHOD. The studies were performed in a preserved and recently expired cadaver donated to the Institut für Anatomie, Westfälische Wilhelms-Universität, Münster. The spinal column from T12 to S1, together with the back musculature (in order to preserve the normal curvature of the spine), were removed from the cadaver. Spinaloscopy was performed with a 4-mm endoscope with a 0 degree optic (Storz, Tuttlingen, Germany). All observations were made in the lumbosacral region of the dissected preparation. The endoscope was inserted from the caudal end of the spinal canal and, depending on the observations being made, the spinal canal was filled with air or artificial cerebrospinal fluid (CSF). To obtain information on the distribution of local anaesthetics injected into the subarachnoid space, 0.5% bupivacaine was coloured with a small amount of 1% methylene blue. The distribution of the coloured anaesthetic was clearly visible during and after injection. RESULTS. Needle insertion: Multiple observations were made using median or paramedian advancement of the needle into the spinal canal. With all needles, including the pencil-point, we saw an unexpected inward movement of the dura to the epidural space before penetration. This dural movement was independent of the direction of the dural fibres in the lumbar area. Distribution of local anaesthetics: Our observations indicate that difficulty with injecting drugs occurred when needle insertion was stopped too close to the dura, especially with the Sprotte needle. After manually registered penetration of the dura, the lateral opening of the needle only partially penetrates the dura. This allows CSF to appear in the needle hub, and injection into the vertical subdural space is possible. In all cases with the Sprotte needle, we could reproduce deposition of methylene-blue-coloured local anaesthetics into the subdural space. With the Quincke and Thuohy needles, it was not possible to deposit local anaesthetics into the subdural space in this model. CONCLUSION. Spinaloscopy was done in a non-fixated anatomic preparation of a spinal column with a 4-mm, 0 degree endoscope. From these observations we conclude that both manually registered penetration of the dural and the appearance of CSF in the needle hub can mimic correct needle position. Especially with the lateral opening of the Sprotte needle, deposition of local anaesthetics in the subdural space is possible.

Anesthesia, Spinal↗
PubMed1994

Bladder distention therapy for symptomatic relief of frequency and urgency: a ten-year review.

OBJECTIVE: A retrospective review was undertaken to determine the efficacy of bladder distention therapy for the treatment of frequency and urgency, and to determine the relative value of prolonged versus short duration distention therapy. METHOD: Prolonged bladder distention therapy was performed on 14 patients and short duration distention on 8 patients over a ten-year period. Indications for the procedure included severe urgency, frequency, and incontinence from a variety of etiologies. RESULTS: Five of 14 patients (18 distentions, 2 bladder ruptures) who had prolonged distention, and 3 of 8 patients (9 distentions, 1 bladder rupture) who had short duration distention experienced symptomatic relief on follow-up (p > 0.7). Since there was no difference between the prolonged and short duration groups, the results were combined to yield 8 of 27 successful distentions (30%) in 8 of 22 patients (36%). All patients with detrusor hyperreflexia failed distention therapy. Complications included 3 cases of bladder rupture, 2 cases of urinary retention, and 1 case of urethral stricture. The rates of bladder rupture were identical in both groups (11%). CONCLUSIONS: The use of prolonged bladder distention therapy has no role in the treatment of detrusor hyperreflexia, and only limited success in the symptomatic relief of severe urgency, frequency, and incontinence of other etiologies. Equal efficacy of prolonged and short duration distention therapy would tend to favor the use of short duration distention to reduce possible anesthesia complications and cost.

Adult↗
PubMed1991

Normal fluctuation of physiologic cardiovascular variables during anesthesia and the phenomenon of "smoothing".

With the advent of automated anesthesia record keeping devices, concern has arisen that "abnormal" values will appear in the record and possibly lead to medicolegal compromise. A retrospective review of automated records from a series of anesthesia cases was undertaken to determine if abnormal values do occur, how frequent they are, and whether they cause problems. A total of 14,826 (4,942 each) noninvasive heart rate, systolic, and diastolic blood pressure readings from 118 case printouts generated by a Diatek Arkive Patient Information Management System (63 cases) or a Datascope Datatrac record keeper (55 cases) were recorded. The study sample covered a broad range of surgical operations, anesthetic procedures, and patient ages and medical histories. During these 118 anesthetics, the majority of readings of all three variables fell within normal ranges (defined for this study as 80 to 180 and 50 to 110 mm Hg for systolic and diastolic blood pressures, respectively, and 60 to 140 beats/min for heart rate). During the anesthetics, 3.6% of the systolic pressure readings, 13.25% of the diastolic readings, and 4.25% of the heart rate readings were recorded outside these ranges. No serious intraoperative or postoperative anesthesia complications were associated with these out-of-range readings, nor would they be expected in a sample of this size, since serious anesthetic complications are rare. This preliminary observation of one person's experience may help address the concern associated with allowing high and low blood pressure and heart rate readings to be automatically recorded "unsmoothed." In medicolegal situations, it should also begin to demonstrate that such fluctuations are neither uncommon nor abnormal, and that a true record of these readings should be neither a cause for concern nor an opportunity for medicolegal exploitation.

Adult↗
PubMed2006

Multiple cesarean section. The impact on maternal and fetal outcome.

OBJECTIVE: To evaluate the complications, and to determine maternal and fetal risks in women who undergo 3 or more cesarean sections (CS), compared to those with one or 2 cesarean deliveries. METHODS: A retrospective analysis of 2276 CS performed between 1 January 2003 and 31 April 2005. We divided patients into 3 groups: Group 1 = with 1 previous CS (n=1183); Group 2 = 2 previous CS (n=781); and Group 3 = >3 previous CS (n=312). RESULTS: Compared to women with one or 2 cesarean deliveries, women who had >3 CS show significant increase in terms of prolonged operative time, uterine scar dehiscence, uterine rupture, placenta previa, placental adherence, and mild adhesion formation. We found no significant differences between the 3 study groups in terms of injury to surrounding structures, need for blood transfusion, anesthesia complications, hematoma formation, thromboembolism, and incisional hernia. Apgar score >7 at one and 5 minutes, neonatal intensive care unit, multiple pregnancy rate, premature delivery rate and perinatal death rate, all were similar in the 3 groups. CONCLUSION: Women with multiple CS (>3) are significantly prone to have uterine scar rupture and abnormal placentation in the subsequent pregnancies compared to those with one or 2 previous cesarean deliveries. Despite that, maternal and neonatal outcome did differ from patients with lower-order cesarean sections.

Cesarean Section, Repeat↗
PubMed2001

Assessment of recovery in patients undergoing intravenous conscious sedation using bispectral analysis.

PURPOSE: The Bispectral Index (BIS) has been recently shown to objectively predict the level of sedation in patients undergoing conscious sedation. It was the goal of this study to directly compare the recovery profile of patients where the BIS was used to monitor sedation with a control group where the monitor was not used. PATIENTS AND METHODS: Forty patients undergoing third molar extractions under intravenous conscious sedation were randomly assigned to 2 groups. In both groups, induction of sedation was performed using a standard dose of fentanyl (1.5 microg/kg) and midazolam (0.05 mg/kg). Propofol was then given in 10 to 20 mg boluses until a clinically desirable sedation level was achieved. In 1 group, the BIS was then monitored continually during surgery using a microcomputer (Aspect-1050 Monitor, Aspect Co, Natick, MA) and recorded at 5-minute intervals. The anesthetist (N.A.S.) provided additional propofol boluses to maintain a BIS level of 70 to 80. In the other group, the BIS sensor was applied, but the monitor was not used. In this group, the sedation was modified, and additional propofol was given based solely on the anesthetist's subjective assessment of the desired level of sedation (Observer's Assessment of Alertness/Sedation [OAA/S] scale level 2 to 3). Additional boluses of 1 mg of midazolam were given during the procedure if patients required repeated boluses of propofol at less than 5-minute intervals to maintain the desired sedation level (BIS level of 70 to 80 or OAA/S level of 2 to 3). These additional midazolam boluses, as well as the time of the last sedative dose (propofol or midazolam) were recorded to study the effect of these factors on recovery. RESULTS: Of the 40 patients initially included in the study, 1 subject in the BIS-monitored group was excluded due to the loss of intravenous access at initiation of the case. For the remaining 39 subjects, 19 were assessed objectively using the BIS monitor, whereas 20 were assessed subjectively using the OAA/S scale. The BIS cases were slightly longer in duration than the OAA/S cases, lasting an average of 26 minutes versus 22 minutes. This difference was statistically nonsignificant (P =.19). Less propofol was used in the BIS cases, with an average of 98 mg for BIS cases versus 106 mg for OAA/S cases (P =.59). The total dose in mg/kg/min was significantly less in the BIS group (0.054 mg/kg/min) than in the OAA/S group (0.074 mg/kg/min; P =.0082). There was no significant difference in the amount of midazolam administered after induction between the 2 groups (P =.60). The surgeon, who was blinded to whether the monitor was used, ranked the third molar extractions more difficult in the BIS group (P =.05). However, patients in the BIS group were on average more cooperative, with better maintenance of muscle tone. The difference in these parameters were nonsignificant (P =.15 and .092, respectively). A positive Romberg test was obtained earlier in BIS patients, although this difference was nonsignificant (P =.097). The straight-line test was completed significantly sooner in BIS patients (P =.013). There was no significant difference between the BIS and OAA/S groups in perceptual speed (P =.55) or computation (P =.32). There was essentially no difference between groups in patient-assessed comfort or recall of the procedure. There were also no notable differences in anesthesia complications, return to activities of daily life, or pain medication use between the 2 groups. CONCLUSIONS: The BIS provides additional information for standard monitoring techniques that helps guide the administration of sedative-hypnotic agents. It appears that use of the BIS monitor can help to titrate the level of sedation so that less drugs are used to maintain the desired level. The trend toward an earlier return of motor function in BIS-monitored patients warrants further investigation.

Adult↗
PubMed2001

Gynecology and obstetrical conditions requiring intensive care admission.

OBJECTIVE: Gynecological admissions to the surgical intensive care unit vary from the obstetrical cases. Pregnant women are of prime age and can tolerate the pregnancy and delivery well. There are certain rare conditions or complications, which make the pregnant women's life pass through a critical time. These are dealt with in a high dependency area, which is short of the intensive care unit. In King Khalid University Hospital there is no such arrangement, so the mildly affected and critically ill patients together are cared for in the surgical intensive care unit. The objective of this study is to study the gynecological and obstetrical conditions requiring intensive care admission in King Khalid University Hospital, surgical intensive care unit. METHODS: All obstetrical and gynecological patients who were admitted to the surgical intensive care unit were included. The demographic particulars, reason for admission, the course of the surgical intensive care unit stay and outcome were studied. RESULTS: During the study period of 3 years, there were 83, (100%) obstetrical and gynecological admissions to the surgical intensive care unit. Two (2%) cases were due to anesthesia complications. The majority of causes of admissions were due to obstetrical (n=63, 76%) complications or combination of medical and surgical conditions. Gynecological admissions comprised only 18 (22%) cases. There was no mortality in the group studied. CONCLUSION: Management of major obstetrical emergencies and gynaecological patients require an understanding of medical conditions' influence on the patients, and the physiological changes of normal and abnormal pregnancies. Intensive care unit management is an essential part in raising the level of patient care; health personnel training and continuing health care education may be improved.

Adult↗
PubMed1995

Extracorporeal shock-wave lithotripsy in children.

OBJECTIVES: To analyze the efficacy and complication rates of extracorporeal shock-wave lithotripsy in children. METHODS: Between 1987 and 1994, 8760 patients with urinary calculi were treated at our institution. A total of 70 (0.8%) children 3 to 14 years old underwent lithotripsy using the Siemens Lithostar or the Lithostar Plus. A total of 100 calculi in 74 urinary tracts were treated, requiring 129 extracorporeal shock-wave lithotripsy sessions. There were 47 caliceal stones, 31 in the renal pelvis, 16 in the ureter, and 6 staghorn stones. The Lithostar Plus was used in 8 patients, for 3 caliceal, 3 pelvic, and 2 staghorn stones. Follow-up consisted of nephrotomogram or ultrasound 1 day and 1 to 3 months postoperatively. RESULTS: Complete removal of all stone fragments was achieved in 98.5% of the patients after 3 months. Re-treatment was necessary in 20 patients (29.4%). All patients were treated as outpatients, 51 (72.9%) with intravenous sedation and 19 (27.1%) without anesthesia. Complications were present in 7 patients (10%) who had colic and received medical treatment, and convalescence was uneventful. CONCLUSIONS: Extracorporeal shock-wave lithotripsy using the Lithostar and the Lithostar Plus has been demonstrated to be an effective noninvasive procedure to treat radiopaque and even radiolucent or slightly opaque urinary calculi in children.

Adolescent↗
PubMed2005

Maternal outcomes in pregnancies complicated by obesity.

OBJECTIVE: To investigate the relationship between prepregnancy obesity and maternal outcomes. METHODS: A 15-year, population-based cohort study using the Nova Scotia Atlee Perinatal Database compared maternal outcomes in obese and nonobese women. Prepregnancy weight of 55-75 kg was considered nonobese, and weight greater than 90 kg was considered obese. Obese women were categorized into moderate obesity (90-120 kg) and severe obesity (> 120 kg) groups. Univariate and multivariable logistic regression analysis was performed, and odds ratios (ORs), adjusted ORs, and 95% confidence intervals (CIs) were calculated. P < .05 was considered statistically significant. RESULTS: In 142,404 singleton pregnancies, 10,134 (7.2%) women were identified as obese (moderate obesity 92.3%, severe obesity 7.7%). The proportion of women in the obese categories increased from 3.2% in 1988 to 10.2% in 2002. Moderately obese women had an increased risk of pregnancy-induced hypertension (PIH) (adjusted OR 2.38, 95% CI 2.24-2.52), antepartum venous thromboembolism (adjusted OR 2.17, 95% CI 1.30-3.63), labor induction (adjusted OR 1.94, 95% CI 1.86-2.04), cesarean delivery (adjusted OR 1.60, 95% CI 1.53-1.67), and wound infection (adjusted OR 1.67, 95% CI 1.38-2.00). Severely obese women had an increased risk of PIH (adjusted OR 3.00, 95% CI 2.49-3.62), antepartum venous thromboembolism (adjusted OR 4.13, 95% CI 1.26-13.54), induction of labor (adjusted OR 2.77, 95% CI 2.39-3.21), cesarean delivery (adjusted OR 2.46, 95% CI 2.15-2.81), anesthesia complications (adjusted OR 2.01, 95% CI 1.33-3.06), and wound infection (adjusted OR 4.79, 95% CI 3.30-6.95). This implies that, relative to nonobese women, there was 1 excess case of PIH per 10 moderately obese women and 1 per 7 severely obese women. For antepartum venous thromboembolism, there was 1 excess case per 857 moderately obese women and 1 per 321 severely obese women. CONCLUSION: Prepregnancy maternal obesity increases the risk of PIH, antepartum venous thromboembolism, labor induction, cesarean delivery, and wound infection.

Adult↗
PubMedDate not supplied

Safety and cost savings of endovascular procedures: are outpatient interventions feasible when combined with open surgery?

As increasing experience and comfort with endovascular interventions performed in an outpatient setting has occurred, the safety and cost effectiveness of performing these procedures without an overnight stay were analyzed, especially when endovascular procedures were combined with open vascular operations requiring an arteriotomy and surgical closure. Ninety patients underwent endovascular procedures alone or concomitantly with open, minor vascular operations to salvage a failing graft between February 1994 and June 1999. Patients undergoing endovascular interventions during primary lower extremity bypass or other major surgical procedures were not included in this review because they were not candidates for outpatient procedures. Balloon angioplasty alone (79) or angioplasty with stent placement (11) was performed to treat stenoses in 50 failing grafts, 16 iliac, 14 femoral, 5 tibial, and 5 axilla/subclavian arteries. A significant increase in outpatient procedures was accomplished as more experience was garnered with these techniques: 19% (8/42) between 1994 and 1996 vs 57% (28/48) between 1997 and 1999 (p = 0.001). Age and comorbidity did not play a role in determining the need for admission because there were no significant differences in patients with diabetes mellitus, hypertension, smoking, or hyperlipidemia and those admitted or discharged the same day (p > 0.05). Patients admitted for overnight observation tended to have longer mean operative times and more complex revascularizations than outpatients (110 vs 69 min, respectively; p < 0.0001). Twenty-seven patients underwent surgical exposure of the access vessel: 63% (17) were admitted and 37% (10) were discharged the same day. Sixty-three patients underwent a percutaneous procedure: 42% (27) were admitted and 58% (37) were discharged the same day. Outpatients were more likely to receive only local anesthesia (83%; 30/35) compared to patients admitted overnight (67%; 36/53); the remaining patients received spinal or epidural anesthesia. Complications included graft thrombosis within 30 days in 6% (5/90) of patients and arterial graft infection in 2% (2). No patient required surgery for bleeding. The average charges for outpatient interventions were $1980 compared to $10,026 for patients who stayed overnight (p < 0.0001). As vascular surgeons become more experienced and comfortable with outpatient endovascular procedures, especially when performed in combination with open minor vascular surgery, significant cost savings can be realized without sacrificing patient safety. Even when open surgical exposure is planned, patients should be instructed preoperatively to anticipate discharge the day of their procedure to minimize resistance to this strategy.

Aged↗
PubMed2000

Impact of the Hawthorne effect in a longitudinal clinical study: the case of anesthesia.

Clinical research can be influenced by many factors that are capable of invalidating results, and one of these factors is known as the Hawthorne effect: the mere awareness of being under observation can alter the way in which a person behaves. In experimental research this effect can be the undesired effect of the experiments themselves, and the stronger its presence, the greater it can influence the results. In anesthesia practice, owing to the particular emotional condition of a patient facing a surgical operation, the Hawthorne effect could be especially strong. The aim of our study was to show the impact that the knowledge of being included in a study has (Hawthorne effect), by comparing the postoperative changes in psychological well-being in two groups of patients undergoing knee arthroscopy and receiving different information about the study from the anesthetist during the preoperative interview. Other signs and symptoms such as postoperative knee pain, nausea, vomiting (the most feared occurrences), headache, return of spontaneous diuresis, analgesic request, anesthesia complications, as well as the intensity of anxiety were also assessed as secondary endpoints. Our results show that subjects who were aware that they were part of a study scored significantly better on postoperative measures of psychological well-being and postoperative knee pain, compared to subjects who were unaware. The size of the effect, as measured by the odds ratio, remains unchanged when controlling for potential confounding factors. The study has enabled us to demonstrate the presence of the Hawthorne effect in clinical research. Therefore, the Hawthorne effect should be acknowledged and accounted for in the design of a study and in the interpretation of results.

Adult↗
PubMed1994

Abortion mortality, United States, 1972 through 1987.

OBJECTIVE: The aim of our study was to describe risk factors for legal abortion mortality and the characteristics of women who died of legal abortion complications for the period 1972 through 1987. STUDY DESIGN: We reviewed abortion mortality surveillance data collected by the Division of Reproductive Health, Centers for Disease Control and Prevention, and calculated rates by various demographic and reproductive health variables using the Center for Disease Control and Prevention's abortion surveillance data as denominators. Rates are reported as legal abortion deaths per 100,000 abortions. RESULTS: Between 1972 and 1987, 240 women died as a result of legal induced abortions. The case-fatality rate decreased 90% over time, from 4.1 deaths per 100,000 abortions in 1972 to 0.4 in 1987. Women > or = 40 years old had three times the risk of death as teenagers (relative risk 3.0, 95% confidence interval 1.5 to 6.0), and black women and those of other minority races had 2.5 times the risk of white women (relative risk 2.5, 95% confidence interval 1.9 to 3.2). Abortions at > or = 16 weeks were associated with a risk of death almost 15 times the risk of death from procedures at < or = 12 weeks' gestation. Women undergoing currettage procedures for abortion had a significantly lower risk of death than women undergoing other procedures. Whereas before 1977 infection and hemorrhage were the leading causes of death, during 1977 through 1982 anesthesia complications emerged as one of the leading causes of death and since 1983 have become the most frequent cause. CONCLUSIONS: Although legal induced abortion-related deaths are rare events, our findings suggest that more rigorous efforts are needed to increase the safety of anesthetic methods and anesthetic agents used for abortions and that efforts are still necessary to monitor serious complications of abortion aimed at further reducing risks of death associated with the procedure.

Abortion, Legal↗
PubMed1993

Complications of regional anesthesia.

Regional anesthesia is fraught with potential risks and complications. Proper training and careful experience with specific techniques will go a long way to improve our skills. Vigilance, conscientiousness, and attention to detail are the qualities that will not only help us to avoid complications, but also help us to detect early signs of developing complications and treat them promptly. Early detection and treatment will improve the ultimate outcome even when complications do occur.

Anesthesia, Conduction↗