Opinion: [on anesthesia for outpatient female sterilization

In actual practice, the choice of anesthesia is more likely to be decided by the personal preference of the surgeon or anesthesiologist rather than by considerations of safety. Most gynecologists in the US and Canada, working in hospitals or surgicenters, choose general anesthesia becaused skilled anesthetists are available, and it is easier for them to operate if their patients are asleep. Most anesthesiologists prefer it that way also, since their services are being fully utilized. During residency training, gynecologists need the benefit of general anesthesia to learn surgical techniques. Because they learned that way, it is the course of least resistance for them to continue to favor general anesthesia. Thus hundreds of thousands of general anesthetics are given each year to suit the convenience and skills of the gynecologist. But minilaparotomy or laparoscopy may be performed with fewer potential complications under local anesthesia, provided the patient receives proper counseling and supportive care, and provided the gynecologist's surgical technique is gentle and precise. Unfortunately, most residency programs do not provide training in such techniques, so they are learned, if at all, during practice years.     

Epidural anesthesia and analgesia in ferrets

Anesthesia and analgesia should be provided to ferrets that are undergoing potentially painful surgical procedures. The epidural route of administration for anesthetic or analgesic drugs can be used. This column outlines the relevant ferret anatomy, indications and contraindications and technique of epidural administration of anesthesia and analgesia in ferrets.     

Open laparoscopy

Many of the complications of conventional closed, or sharp, laparoscopy result from the use of insufflation needles and sharp trocars. These instruments are not essential elements of the technique as laparoscopy can be easily performed with a small umbilical incision, entering the abdomen under direct vision. This variation is called open laparoscopy. Open laparoscopy eliminates the possibility of insufflation-needle and trocar injuries and lessens the probability of failed laparoscopy attempts and postoperative herniations. Furthermore, physicians performing open laparoscopy can become comfortably proficient in the technique faster than they can in closed laparoscopy because open laparoscopy utilizes standard and familiar surgical technique. Open laparoscopy can be easily performed under local anesthesia, particularly for female sterilization. The technique is suitable for the outpatient setting based on considerations of safety and reliability.     

The Use of Paracervical Block Anesthesia for Dilatation and Curettage

Paracervical block anesthesia was used for dilatation and curettage in 37 patients in situations where general anesthesia or sophisticated forms of conduction anesthesia were either unavailable or contraindicated. Ten millilitres of either 1% xylocaine or procaine or 5 ml. of 2% xylocaine was placed into each lateral fornix with a standard 6-inch, 20-gauge needle at a depth of six to 12 millimetres. The block''s effect was good in 34 cases and fair in three; there were no failures. No significant complications occurred. The necessity of guarding against and/or being prepared to treat local anesthetic sensitivity is recognized. Paracervical block proved to be a convenient, safe, simple and effective anesthetic technique for dilatation and curettage, including when other anesthetic techniques were contraindicated.     

Regional anesthesia for major vascular surgery.

The relative merits of general vs regional anesthesia for patients undergoing major vascular surgery has been the subject of debate over the past decade. Previous studies of regional vs general anesthesia often were deficient in experimental design and, therefore, did not produce definitive answers. Some of these deficiencies related to non-standardized, poorly conducted, and/or described general anesthetic techniques, nonstandardized methods of postoperative analgesia in the general anesthesia groups, and variations in preoperative cardiac status in the study groups. Furthermore, most studies did not conclusively demonstrate a cause and effect relationship between the proposed mechanisms of the beneficial effect of regional anesthesia and outcome. Recent studies, however, have claimed improvements in outcome following regional anesthesia in patients undergoing peripheral vascular procedures. The reported beneficial effects have included amelioration of the neuroendocrine stress response to surgery, improvement in pulmonary function, cardiovascular stability, enhancement of lower limb blood flow, reduction in the incidence of graft thrombosis, and a reduction in the thrombic response to surgery. Skeptics still question whether recent studies have the power to determine whether regional anesthesia decreases the incidence of cardiac and pulmonary complications following major vascular surgery. Furthermore, the issue of whether the beneficial effects of regional anesthesia on the incidence of graft thrombosis and the thrombotic response to surgery relating to intraoperative or postoperative regional anesthesia/analgesia, to regional anesthesia per se, or to the systemic effects of absorbed local anesthetics remains unresolved.     

Mandibular and maxillary anesthesia; uses of the conduction technique

A series of techniques for obtaining specific nerve-block anesthesia of the oral cavity and jaws is examined in relationship to the anatomical site to be anesthetized, whether for operation or diagnosis. This method of anesthesia is considered superior to the field-block approach-that is, the general diffusion of anesthetic agent through or about the proposed operative site. The final goal of a surgeon using local anesthesia is the gaining of specific nerve-block anesthesia as a prelude to operation.     

MANDIBULAR AND MAXILLARY ANESTHESIA—Uses of the Conduction Technique

A series of techniques for obtaining specific nerve-block anesthesia of the oral cavity and jaws is examined in relationship to the anatomical site to be anesthetized, whether for operation or diagnosis.This method of anesthesia is considered superior to the field-block approach—that is, the general diffusion of anesthetic agent through or about the proposed operative site.The final goal of a surgeon using local anesthesia is the gaining of specific nerve-block anesthesia as a prelude to operation.     

Do inhalation general anesthetic drugs induce the neuronal release of endogenous opioid peptides?

The antagonism of some effects of inhalation general anesthetic agents by naloxone suggests that there may be an opioid component to anesthetic action. There is evidence that this opioid action component is due to neuronal release of endogenous opioid peptides. The strongest evidence is provided by studies that monitor changes in the concentration of opioid peptides in the perfused brain following inhalation of the anesthetic. Indirect or circumstantial evidence also comes from studies of anesthetic effects on regional brain levels of opioid peptides, antagonism of selected anesthetic effects by antisera to opioid peptides and anesthetic-induced changes radioligand binding to opioid receptors. It is likely that some inhalation general anesthetics (e.g., nitrous oxide) can induce neuronal release of opioid peptides and that this may contribute to certain components of general anesthesia (e.g., analgesia). More definitive studies utilizing in vivo microdialysis or autoradiography in selected areas of the brain during induction and successive states of general anesthesia have yet to be conducted.     

Female sterilization by Falope ring ligation.

Sterilization with the Falope Ring may be performed by means of laparoscopy of the minilaparotomy. This technique avoids the potential hazards of electrocoagulation, such as intestinal burns. Among the 825 cases reported in this paper there was only one serious complication, an ectopic pregnancy. One other patient had an undetected early pregnancy at the time of sterilization. Two patients became pregnant 4 and 42 month after the procedure. In most cases a diagnostic dilatation and curettage was done before hand. Pathological study of the fallopian tubes of one patient 28 days after the ring was applied revealed complete occlusion of the buckled segment of each tube. Falope Ring sterilization is simple, effective and safe, and the rate of subsequent pregnancy is lower than with conventional burning or clipping techniques.     

Oral premedication for operations on the face under local anesthesia: a placebo-controlled double-blind trial.

Modern strategies for preventing or controlling pain and anxiety demand a premedication for operations using local anesthesia and for those using sedation or general anesthesia. For optimal patient care, the premedication should be given orally and, with respect to the outpatient basis of the operations, should have a short recovery period. Midazolam, one of the most favored premedications for general anesthesia, has been recommended as a premedication for operations using local anesthesia as well. However, midazolam has only sedative-anxiolytic effects and does not reduce pain sensation, which should be mandatory for operations using local anesthesia. A further requirement is the maintenance of stable hemodynamics for the prevention of postoperative hematomas, especially in the face. For these reasons, another premedication meeting all requirements (anxiolysis, analgesia, and stable hemodynamics) was researched. A randomized, double-blind prospective study was performed from March of 1997 to June of 1998. Five groups totalling 150 patients were included in the study; each group contained 30 patients who had operations performed solely on the face. In the first four groups, the effect of midazolam (0.15 mg/kg(-1)), morphine (0.3 mg/kg(-1)), and clonidine (1.5 microg/kg(-1)) administered orally was compared with a placebo. The fifth group was the control group and received no premedication. To evaluate the effects of the premedications, a corresponding questionnaire was completed independently by the patient and surgeon. With regard to the anxiolytic or analgesic properties of the premedication, 61 percent of the patients preferred pain reduction to anxiety control, and 24 percent of patients preferred reduction of anxiety. The remainder insisted on a reduction of both properties (8 percent) or had no preference (7 percent). Reduction of anxiety was largest in the midazolam and the clonidine groups, but the difference was not significant. The least pain during the application of local anesthesia was experienced by the morphine group (37 percent) and the clonidine group (33 percent), in contrast to the midazolam group (60 percent) (p = 0.04). Morphine and clonidine met the requirements of pain reduction equally well. Nevertheless, considering the rate and intensity of adverse effects with respect to hemodynamic compromises, nausea, and emesis, clonidine is even better suited as an oral premedication for operations on the face using local anesthesia.     

Le bloc paracervical en obstétrique

Local anesthesia can be very useful in the first stage of labour when a general anesthetic cannot be given during this stage, and it is associated with reduced respiratory depression in the fetus. Paracervical block anesthesia is one such method of local anesthesia. Its successful use depends upon a proper technique, knowledge of the indications and contraindications, appropriate equipment and use of a long-acting anesthetic agent of low toxicity. A series of 90 cases of paracervical block are described in which the success rate was 90 to 95%.     

Incidence and predictors of immediate complications following perioperative non-obstetric epidural punctures

Background

We made a survey among Finnish anesthesiologists concerning the current perioperative anesthetic practice of hip fracture patients for further development in patient care.

Methods

All members of the Finnish Society of Anesthesiologists with a known e-mail address (786) were invited to participate in an internet-based survey.

Results

The overall response rate was 55% (423 responses); 298 respondents participated in the care of hip fracture patients. Preoperative analgesia was mostly managed with oxycodone and paracetamol; every fifth respondent applied an epidural infusion. Most respondents (98%) employed a spinal block with or without an epidural catheter for intraoperative anesthesia. Midazolam, propofol and/or fentanyl were used for additional sedation. General anesthesia was used rarely. Postoperatively, paracetamol and non-steroidal anti-inflammatory drugs and occasionally peroral oxycodone, were prescribed in addition to epidural analgesia.

Conclusions

The survey suggests that the impact of more individualised analgesia regimens, both preoperatively and postoperatively, should be investigated in further studies.     

Propofol anesthesia in loggerhead (Caretta caretta) sea turtles

Rapid, safe, and effective methods of anesthetic induction and recovery are needed for sea turtles, especially in cases eligible for immediate release. This study demonstrates that intravenous propofol provides a rapid induction of anesthesia in loggerhead (Caretta caretta) sea turtles and results in rapid recovery, allowing safe return to water shortly after the procedure. Forty-nine loggerhead sea turtles were recovered as local fishery by-catch in pound nets and transported to a surgical suite for laparoscopic sex determination. Treatment animals (n = 32) received 5 mg/kg propofol intravenously (i.v.) as a rapid bolus, whereas control animals (n = 17) received no propofol. For analgesia, all animals received a 4 ml infusion of 1% lidocaine, locally, as well as 2 mg/kg ketoprofen intramuscularly (i.m.). Physiologic data included heart and respiratory rate, temperature, and a single blood gas sample collected upon termination of the laparoscopy. Subjective data included jaw tone and ocular reflex: 3 (vigorous) to 0 (none detected). Anesthetic depth was scored from 1, no anesthesia, to 3, surgical anesthesia. Turtles receiving propofol became apneic for a minimum of 5 min with a mean time of 13.7 +/- 8.3 min to the first respiration. Limb movement returned at a mean time of 21.1 +/- 16.8 min. The treatment animals were judged to be sedated for approximately 30 min (mean anesthetic depth score > or = 1.5) when compared to controls. Median respiratory rates for treatment animals were slower compared to controls for the first 15 min, then after 35 min, they became significantly faster than the controls. Median heart rates of control animals became significantly slower than treatment animals between 40 and 45 min. Physiologic differences between groups persisted a minimum of 55 min. Possible explanations for heart rate and respiratory rate differences later in the monitoring period include a compensatory recovery of treatment animals from anesthesia-induced hypoxia and hypercapnia or, alternatively, an induced response of the nonsedated control animals. The animals induced with propofol were easier to secure to the restraint device and moved less during laparoscopy. In conclusion, propofol is a safe and effective injectable anesthetic for use in free-ranging loggerhead sea turtles that provides rapid induction and recovery.     

Effects of isoflurane concentration on basic echocardiographic parameters of the left ventricle in rats

Transthoracic echocardiography (TTE) has become an important modality for the assessment of cardiac structure and function in animal experiments. The acquisition of echocardiographic images in rats requires sedation/anesthesia to keep the rats immobile. Commonly used anesthetic regimens include intraperitoneal or inhalational application of various anesthetics. Several studies have compared the effects of anesthetic agents on echocardiographic parameters in rats; however, none of them examined the effects of different concentrations of inhalational anesthetics on echocardiographic parameters. Accordingly, the aim of this study was to examine the effects of different concentrations of isoflurane used for anesthesia during TTE examination in rats on basic echocardiographic parameters of left ventricular (LV) anatomy and systolic function. TTE examinations were performed in adult male Wistar rats (n=10) anesthetized with isoflurane at concentrations of 1.5-3 %. Standard echocardiograms were recorded for off-line analysis. An absence of changes in basic echocardiographic parameters of LV anatomy and systolic function was found under isoflurane anesthesia using concentrations between 1.5-2.5 %. An isoflurane concentration of 3 % caused a small, but statistically significant, increase in LV chamber dimensions without a concomitant change in heart rate or fractional shortening. For the purpose of TTE examination in the rat, our results suggest that isoflurane concentrations 相似文献   

General anesthesia in an office-based plastic surgical facility: a report on more than 23,000 consecutive office-based procedures under general anesthesia with no significant anesthetic complications

The popularity of elective office-based plastic surgery has increased significantly over the past two decades. The continuing demand for improved aesthetic results has stimulated the development of ever more complex plastic surgical techniques. These techniques may require extended periods of operative time spent under anesthesia. Patients have come to expect an almost perfect anesthetic and surgical experience, with safety and comfort being their foremost concerns. Because of increasingly complex and lengthy operations, the authors believe that intravenous sedation, used for many years in their plastic surgery practice, is now suboptimal for most longer and complex surgical procedures. In their experience, under most circumstances, general anesthesia provides the optimal anesthetic experience for the patient, anesthesiologist, and surgeon. The authors present a consecutive 18-year study of general anesthesia in more than 23,000 procedures in an accredited, office-based plastic surgical facility that offers a very safe and uniformly pleasant anesthesia experience for patients. There were no intraoperative or postoperative deaths and no significant complications. The authors' experience differs from the common perception that general anesthesia is too risky for aesthetic surgery procedures.     

Soft-tissue expansion: concepts and complications

Soft-tissue expansion complements existing reconstructive techniques and provides new vistas for the plastic surgeon. The technique finds use for overcoming a shortage of tissue, for obtaining skin with special desirable qualities, for creation of flaps otherwise not possible because of the resultant donor site or limited vascularity, for creation of flaps with functioning muscle and overlying soft tissue, and for minimizing flap donor-site problems. Careful planning should include patient counseling, optimum incision placement, and time for a leisurely, complete expansion. The surgery can often be performed under local anesthesia and expansion is tolerated well. Patients should be counseled that the incidence of major complications in an unselected series is 1 in 4 patients. Major complications, however, typically result in a delay in reconstruction and not tissue loss.     

A new anesthetic agent for use in the gerbil

Gerbils have been neglected in published reports on anesthesia. This study compared several dosages of Telazol used for anesthesia in the gerbil. Each group of animals injected with Telazol was evaluated for onset and duration of anesthesia and analgesia. Results showed Telazol to be a safe anesthetic and when dosed at 60 mg/kg to be suitable for major surgical procedures. Lower dosages of Telazol, in contrast, provided immobility and analgesia suitable for less nocioceptive and noninvasive experimental manipulations. Dosages of Telazol required for surgical depth of analgesia and anesthesia were accompanied by a prolonged recovery time. Gerbils should be monitored closely to insure a safe recovery when using the higher dosages.     

From analgesia to myopathy: When local anesthetics impair the mitochondrion

The expanding utilization of local anesthesia and analgesia revealed the occurrence of myopathies induced by local anesthetics. Such iatrogenic effect encouraged anesthesiologists to study the toxicity of local anesthetics and to reevaluate their protocols in order to reduce muscle pain and dysfunction. Studies performed in rats and human cells showed that bupivacaine induces muscle histological damages with sarcomers disruption along with structural alteration of mitochondria, the powerplant of the cell. Bupivacaine-induced myopathies (BIM) are underestimated as patients are not examined by the anesthesiologist after the surgery. Biochemical analyses indicate that BIM could be explained both by the alteration of mitochondrial energetics with consecutive oxidative stress and mitophagy, and the modification of sarcoplasmic reticulum activity with perturbations of calcium homeostasis. BIM is time-dependent, local anesthetic concentration-dependent, enhanced by preexisting metabolism alteration or young age, and could be prevented in part by antioxidant agents and rhEPO. These observations suggest that adapted changes in postoperative analgesia protocols, including the adjustment of LA concentration and volume, a more precise delivery of the drug and an adapted duration of analgesia, may prevent myopathies consecutive to local anesthesia.     

Neuroaxial anesthesia in a patient with progressive systemic sclerosis : case presentation and review of the literature on systemic sclerosis

Background

Systemic sclerosis (SSc), a progressive disease characterized by excessive accumulation of connective tissue components. Although most patients have long survival, some of them progress rapidly to death. Pulmonary system involvement and pulmonary hypertension are the most frequent cause of death. When the patient with SSc is to be operated, the anesthetic procedure could be a serious problem. In this article, we report a combined spinal – epidural technique in a patient with progressive SSc and the anesthetic considerations that could be recommended for these patients.

Case presentation

A 68-year-old woman who had a history of progressive systemic sclerosis, pulmonary fibrosis, kyphoscoliosis and decreased oral apertura underwent total hip arthroplasty. This operation was performed successfully under combined spinal epidural anesthesia.

Conclusion

Systemic sclerosis is a complex disease that involves multiple organ systems. Every aspects of anesthetic care may be altered or hindered by the pathogenesis of disease. Although the choice of regional or general anesthesia is unclear, to choose combined spinal epidural anesthesia may be useful.