Rectal indomethacin to supplement opioid infusion.
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STUDY OBJECTIVES: To investigate changes in both core and peripheral skin-surface temperatures during and after application of a unilateral leg pneumatic tourniquet in adult patients. DESIGN: Prospective, observational clinical study. SETTING: University hospital. PATIENTS: 21 ASA physical status I and II adult patients scheduled for elective leg orthopedic surgery with lumbar epidural anesthesia. INTERVENTIONS: Rectal and fingertip skin-surface temperatures were recorded every minute after steady-state lumbar epidural anesthesia was established. MEASUREMENTS AND MAIN RESULTS: Significant (p < 0.05) increases in both rectal and fingertip temperatures were observed during tourniquet application for 91 +/- 6 minutes from 36.5 +/- 0.14 degrees C to 37.0 +/- 0.17 degrees C and from 32.6 +/- 0.79 degrees C to 35.5 +/- 0.44 degrees C, respectively. In contrast, both rectal and fingertip temperatures progressively decreased following tourniquet release; significant (p < 0.05) decreases in the rectal and fingertip temperatures were observed 6 and 5 minutes after tourniquet release, respectively. Decreases (approximately maximum) in the rectal and fingertip temperatures 15 minutes after tourniquet release were 0.25 +/- 0.05 degrees C and 1.26 +/- 0.26 degrees C, respectively. In each case, changes in fingertip temperature were approximately six times greater than those in the rectal temperature. CONCLUSIONS: Limb tourniquets appear to cause thermal perturbations during epidural anesthesia. The progressive increases in core temperature during tourniquet application presumably resulted from constraint of metabolic heat to the core thermal compartment, and the greater increases in the skin-surface temperature during tourniquet application appear to represent vasodilation in response to the core hyperthermia. On the other hand, redistribution of body heat and the efflux of hypothermic venous blood from the tourniqueted area into systemic circulation following tourniquet deflation probably decreased the core temperature, which might switch off the thermoregulatory vasodilation, leading to the decreases in skin-surface temperature. Recognition of these thermal perturbations are useful in diagnosing intraoperative thermal perturbations.
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OBJECTIVES: To introduce two forms of anesthesia and compare them with standard local anesthesia techniques. METHODS: A total of 114 consecutive patients underwent prostate needle biopsy. The patients were sequentially randomized to receive different kinds of anesthesia: 2% rectal lidocaine gel, 40% dimethyl sulfoxide (DMSO) with lidocaine, perianal injection of 1% lidocaine, or periprostatic nerve block. Pain perception was separately assessed for probe insertion and biopsies using a visual pain analog score. One-way analysis of variance was used to compare the data scale among the four groups. A linear regression model was used to define the independent variables that predicted the level of pain. RESULTS: The groups were similar in terms of age, prostate-specific antigen levels, digital rectal examination findings, prostate volume, pain tolerance, biopsy time, and number of cores taken. The lowest pain scores for probe insertion were for the perianal injection and DMSO/lidocaine groups (0.89 and 1.38, respectively). The difference between these scores and those for the other two groups was statistically significant (P <0.001). Pain perception during biopsy did not differ significantly among the DMSO/lidocaine, perianal, or periprostatic groups and was greatest in the lidocaine gel group (4.147; P <0.001). We did not observe any statistically significant correlation between the pain level during probe insertion and biopsy and pain tolerance (P = 0.514 and P = 0.788, respectively). The anesthesia type was the strongest single predictor of the pain level during biopsy (P <0.001). CONCLUSIONS: The use of 40% DMSO with lidocaine instilled into the rectal vault for 10 minutes avoids any need for injection and is capable of decreasing the discomfort or pain experienced during probe insertion and prostate biopsy comparable to the perianal and periprostatic protocols.
The effects of the rectal premedication and the mother's presence on induction of anesthesia were studied with 67 children between the ages of 1 and 6 years. All children were induced with mask using nitrous oxide-oxygen-halothane. Children's emotional states during induction were categorized as excellent, good or fair. Rating of excellent or good was considered to indicate satisfactory induction. Forty-seven children were accompanied by their mother. Twenty-two of them were premedicated with rectal bromazepam (3 mg), while another twenty-five children were not premedicated. Satisfactory induction after premedication was performed on 78% of the 1-3 year olds and 100% of the 4-6 year olds, whereas without rectal premedication, satisfactory induction was achieved in 42% of the 1-3 year olds and 69% of the 4-6 year olds. Rectal premedication was important for satisfactory induction. Another twenty of all children were premedicated with rectal bromazepam (3 mg) and induced without mother presence. Satisfactory induction was performed on 38% of the 1-3 year olds and 100% of the 4-6 year olds. Mother's presence tended to lead to satisfactory induction. Furthermore, we sought feedback from the mothers about their presence during induction of anesthesia. Almost all of the mothers said they appreciated the opportunity to be present, with the exception of four mothers (8.5%) who reported feeling of some anxiety to be in an operating room.
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We investigated the utility of an infrared ear thermometer (M 10, Terumo) as an intraoperative core temperature monitor. Temperatures of the axilla and inner ear were measured before and after anesthesia. Bladder, rectal, and forehead deep temperatures were continuously measured using a core temperature monitor (CTM-205, Terumo) during anesthesia. At the same time, the temperature of the inner ear was measured 4 times every 15 minutes (twice from cephalad and twice from caudal directions). There were no significant differences in the measured inner ear temperatures, either between directions of measurement or between the 1st and 2nd measurements. The inner ear temperature showed a close correlation with rectal, bladder, forehead deep, and axillary temperatures (r = 0.72-0.79, P < 0.01). The smallest temperature difference in this study was found to be that between the inner ear and forehead deep temperatures (-0.10), and the limit of agreement between these temperatures was also the smallest (0.81). In conclusion, we recommended the use of an infrared ear thermometer as an intraoperative core temperature monitor, especially in lower abdominal surgery, in which neither rectal nor bladder temperature monitoring is reliable.
Twenty patients seen at Boston City Hospital required general or spinal anesthesia for rectal injuries, and 17 required laparotomy. Findings on sigmoidoscopy were falsely negative in 4 of 13 patients examined. Diagnosis was delayed in two patients. Associated injuries occurred in 55 percent, with the lower genitourinary tract being the area most frequently injured. Complications occurred in eight patients (40 percent). Abscess formation and bacteremia were the most common, but iatrogenic complications occurred in four patients. Pulmonary embolism occurred in two patients and was suspected in a third patient. Routine treatment included diverting colostomy with distal irrigation and adequate drainage. Repair of the injury was performed when possible. Two of the 20 patients (10 percent) died, one after a prolonged septic course and one from recurrent pulmonary embolism. Rectal trauma continues to be a challenging injury.
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We have recently shown that brain temperature can drop even though rectal and skull readings are maintained near 37 degrees C during global forebrain ischemia in the gerbil. In this study gerbils were subjected to 5 min of ischemia followed by 85 min of extended halothane anesthesia, while rectal and skull temperatures were kept at normal values. This extended anesthesia procedure prevented the development of spontaneous postischemic hyperthermia. However, it occasionally produced mild brain hypothermia both during ischemia and throughout anesthesia. In addition, the degree of brain hypothermia positively correlated with CA1 preservation; with some gerbils showing complete protection. In contrast, animals with normal brain temperature displayed extensive CA1 cell loss. These data suggest that postischemic hyperthermia is not a prerequisite for extensive CA1 loss in gerbils exposed to 5 min of ischemia. Second, rectal and skull recordings are not always reliable indicators of brain temperature, especially during anesthesia.
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Selective rectal or sphincter neurostimulation aiming at controlled defecation was performed in 10 dogs. While the dogs were under anesthesia, the rectal and rectal neck pressures, balloon expulsion as well as external anal sphincter (EAS) response to stimulation of the second sacral ventral nerve root (S2) and its autonomic and somatic branches were determined. Each of these nerves was stimulated separately using bipolar platinum cuff electrodes. S2 stimulation resulted in rectal and rectal neck pressure elevation as well as increase of EMG activity of EAS without balloon expulsion. Autonomic branch stimulation effected rectal pressure increase and balloon expulsion, while somatic branch stimulation caused increase of rectal neck pressure and EAS EMG activity with no balloon expulsion. S2 stimulation with somatic branch transection produced rectal pressure elevation and balloon expulsion. In contrast to rectal pressure, the rectal neck pressure increased with increasing stimulus frequency. In conclusion, rectal evacuation and sphincteric control could be induced by selective sacral root electrostimulation: S2 stimulation with transection of the somatic branch for the former and pudendal branch stimulation for the latter.
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Changes in concentrations of cortisol and progesterone in serial blood samples were used to quantify a stress response to different methods of electroejaculation in 10 Hereford bulls. Treatments included restraint (control), and electroejaculation using rectal probes with segmented electrodes or conventional nonsegmented electrodes, with or without lidocaine caudal epidural anesthesia. A subjective scoring system was used to assess behavioral responses to the different methods of electroejaculation. The increases in concentrations of serum cortisol and progesterone after electroejaculation were higher for all electroejaculation treatments than for restraint alone. The increases in serum progesterone concentrations were significantly lower at 5 and 20 minutes after electroejaculation with epidural anesthesia than with no anesthesia. However, the change in cortisol or progesterone concentrations did not differ after electroejaculation when comparing the conventional probe or a segmented probe at any time during the study. Subjective scoring showed no differences among electroejaculation methods. Use of epidural anesthesia was beneficial in reducing progesterone, one indicator of an endocrine stress response to electroejaculation.
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