Anesthesia for outpatient female sterilization

This issue of the Bulletin deals with the principles of anesthesia for outpatient female sterilization with emphasis on techniques for laparoscopy and minilaparotomy. General anesthesia techniques provide analgesia, amnesia, and muscle relaxation and are particularly useful for managing the anxious patient. Disadvantages include increased expense, need for specialized equipment, and highly trained personnel, and delayed recovery. Complications, though relatively rare, can be life-threatening and include aspiration of stomach contents, hypoxia, hypercarbia, hypotension, hypertension, cardiac arrhythmias, cardiorespiratory arrest, and death. There is no single preferred technique of general anesthesia, athough most anesthetists employ methods that allow rapid recovery of faculties, enabling the patient to be discharged soon after surgery. To accomplish this end, light anesthesia with sodium thiopental induction and nitrous oxide maintenance is often used. Short duration muscle relaxation with an agent such as succinylcholine supplements this technique. Other techniques include light anesthesia with inhalational anesthetic agents and the use of intravenous ketamine. Local anesthesia augmented by systemic and/or inhalational analgesia is supplanting general anesthesia techniques for laparoscopy in many locales. This approach is also particularly well-suited for minilaparotomy in developing countries, where it has achieved its greatest popularity. The local technique carries with it reduced morbidity and mortality but may not entirely relieve discomfort. The primary danger of local anesthesia is respiratory depression due to excessive narcosis and sedation. The operator must be alert to the action of the drugs and should always use the minimal effective dose. Although toxicity due to overdosage with local anesthetic drugs is occasionally experienced, allergic reactions to the amide-linkage drugs such as lidocaine or bupivacaine are exceedingly rare. For outpatient laparoscopy or minilaparotomy, local anesthesia with proper preoperative counselling and premedication should provide adequate relief of pain and is the method of choice, unless the patient cannot be examined awake or is totally uncooperative. The decision to utilize either general or local anesthesia should be made by the patient after thorough counselling by the surgical team. In many cases, the circumstances of the surgical environment will dictate the choice, but patient comfort and safety should always be the goal.     

ST-segment elevation associated with allergic reaction to echocardiographic contrast agent administration

We report a case of an allergic reaction after the administration of an echocardiographic contrast agent which resulted in ST-segment elevation. Hypersensitivity and allergic reactions are known causes of acute cardiovascular events. However, only limited reports are available which suggest the exact mechanism of the occurrence of angina or myocardial infarction during severe allergic reactions. In our case, through invasive imaging (coronary angiography and IVUS) we have shown for the first time a transient coronary spasm in the absence of intra-coronary thrombus and only minimal neointimal hyperplasia.     

The effect of general anesthesia on memory in experimental animals

Full recovery of short-term memory (maximum time of delayed reactions) and of the structure of situational conditioned reflex and differentiation inhibition in dogs is observed in 1.5-2.5 h after tranquil-anaesthesia (diazepam-ketamine in doses of 0.3-15 mg/kg correspondingly) and dissociative anaesthesia by ketamine (15 mg/kg) in 6-8 h after neuroleptanalgesia (droperidol-fentanyl 2.5-0.05 mg/kg correspondingly), 20-24 h after narcosis by thiopental sodium (30 mg/kg) and by the end of the 3d day after neuroleptanaesthesia (droperidol-ketamine 2.5-15 mg/kg correspondingly). The recovery of the reaction of memory trace reproduction (of conditioned reaction of passive avoidance in rats) after various types of general anaesthesia is observed mainly in the same sequence, but on the average a day later than the short-term memory in dogs.     

Inhalation anesthesia in adult cattle

An inhalation technique was used for anesthesia during ileal cannulation in five adult cows. Following sedation with intravenous acepromazine, anesthesia was induced intravenously with thiopental sodium in 5% glyceryl guaiacolate solution. Endotracheal intubation was performed and anesthesia maintained with halothane in oxygen via a circle system with a precision vaporizer. In all cases, induction was smooth and no difficulties were experienced during the maintenance of anesthesia. Total anesthesia time was 1.5 to 2.5 hours. Following completion of the surgical procedure, which was performed with the animal in left lateral recumbency, each cow was rolled to a sternal position and supported, if necessary. The endotracheal tube was left in place, with oxygen administration continued, until the animal was able to swallow. Recoveries were rapid and all animals were ambulatory within 30 minutes after completion of the surgery. The only post-operative complication due to anesthesia was transient mouth soreness in two cases, attributed to the use of a mouth speculum during intubation.     

Tourniquet-induced ischemia-reperfusion injuries during extremity surgery at children's age: impact of anesthetic chemical structure

Abstract

Objectives

The aim of this study was to determine the relationship between the antioxidant profile of anesthetics and its relation to total antioxidant capacity (TAC) of plasma in children who underwent tourniquet-induced ischemia-reperfusion (IR) injury during extremity operations.

Methods

Children were randomized into three groups: general inhalational anesthesia with sevoflurane (group S), total intravenous anesthesia (TIVA) with propofol (group T), and regional anesthesia (group R). Venous blood samples were obtained before peripheral nerve block and induction of general anesthesia (baseline), 1 minute before tourniquet release (BTR), and 5 and 20 minutes after tourniquet release (ATR). Plasma TAC as well as antioxidant potential of propofol, thiopental, and bupivacaine were measured using the 2,2-diphenyl-1-picrylhydrazyl (DPPH) assay.

Results

Plasma TAC in group T was increased significantly at 20 minutes ATR in comparison with basal and BTR values, and also was significantly higher in comparison with plasma TAC in groups S and R measured at the same time point. The radical scavenging activity of anesthetics in vitro indicated that only propofol possessed a significant antioxidative activity in the reaction with DPPH radical in comparison with thiopental and bupivacaine.

Discussion

These data confirm that TIVA with propofol attenuates oxidative stress related to tourniquet-induced ischaemia-reperfusion injury in children.     

猪全胰十二指肠移植术的麻醉技术及围术期管理探讨

目的-以肠内引流(enteric drainage,ED)和门静脉回流(Portal venous drainage,PVD)术式,建立猪全胰十二指肠移植模型,探讨该术式的麻醉及围术期管理方法,为临床胰腺移植积累经验。方法-供、受体猪各20只,基础麻醉后建立心电监护,硫喷妥钠静脉诱导,暴露声门后,静注司可林气管插管,机控呼吸,术中以芬太尼、咪唑安定、哌库溴铵、硫喷妥钠维持麻醉。直视下右颈总动脉、右颈外静脉穿刺置管,连续监测并记录平均动脉压、心率、经皮脉搏氧饱和度及中心静脉压,测定血糖及胰岛素、胰高血糖素水平。结果-成功建立胰腺移植模型并改进了诱导插管方法,气管插管一次成功率95％。采用静脉复合麻醉,苏醒迅速、安全。无胰期积极扩容可保证新胰灌注后呼吸循环稳定。     

Determination of thiopental in urine sample with high-performance liquid chromatography using iodine-azide reaction as a postcolumn detection system

The reaction between iodine and azide ions induced by thiopental was utilized as a postcolumn reaction for chromatographic determination of thiopental. The method is based on the separation of thiopental on an Nova-Pak CN HP column with an acetonitrile-aqueous solution of sodium azide as a mobile phase, followed by spectrophotometric measurement of the residual iodine (lambda=350 nm) from the postcolumn iodine-azide reaction induced by thiopental after mixing an iodine solution containing iodide ions with the column effluent containing azide ions and thiopental. Chromatograms obtained for thiopental showed negative peaks as a result of the decrease in background absorbance. The detection limit (defined as S/N=3) was 20 nM (0.4 pmol injected amount) for thiopental. Calibration graphs, plotted as peak area versus concentrations, were linear from 40 nM. The elaborated method was applied to determine thiopental in urine samples. The detection limit (defined as S/N=3) was 0.025 nmol/ml urine. Calibration graphs, plotted as peak area versus concentrations, were linear from 0.05 nmol/ml urine. Authentic urine samples were analyzed, thiopental was determined at nmol/ml urine level.     

Effect of the agents of general anesthesia on mice after microwave irradiation]

The general anesthetics chloroform, ftorotan, sodium thiopental and sodium hydroxybutyrate (500 mg/kg) decrease the survival of mice irradiated by microwaves. Ether, ftorotan, hexenal and sodium thiopental administered immediately after irradiation reduce the time of ensuing side position by 8-14%, its duration being decreased by 15-48% as compared to the control.     

Relationship between brain mitochondrial hexokinase and neuronal function

Mitochondrially bound brain hexokinase is solubilized by anesthetics and this effect has been suggested to contribute to anesthesia. In the present investigation the influence of the metabolic inhibitor 2-deoxy-D-glucose (2-DOG) was studied. An isolated rat brain preparation was used to avoid the contribution of peripheral reactions. Isolated rat brains were perfused for 45 min with media containing 4 mmol/l glucose, 10 mmol/l 2-DOG and/or 0.4 mmol/l thiopental. The EEG was monitored and acetylcholine, 2-DOG and its 6-phosphate, as well as the intracellular distribution of hexokinase activity were determined in brain tissue. Soluble hexokinase activity in brain cortex was enhanced by 2-DOG, as also by thiopental, and even more pronounced by both drugs used together. Results from in vitro experiments suggest that solubilization of mitochondrial hexokinase after 2-DOG is mediated by intracellularly accumulated 2-DOG-6-phosphate. 2-DOG produced a significant impairment of neuronal activity, revealing EEG patterns similar to those caused by thiopental anesthesia. Cortical acetylcholine levels were elevated by 2-DOG, as well as by thiopental, and again both drugs showed an additive effect when used in combination. This effect which may be the result of an inhibition of acetylcholine release, was also detectable in mice in vivo after 5 g 2-DOG/kg i.p., whereas the same dose of 3-O-methylglucose had no effect. The results provide further evidence that mitochondrial hexokinase may be involved in the relationship between cerebral metabolism and brain function.A preliminary report of these results has been made at the 22^nd spring meeting of the Deutsche Pharmakologische Gesellschaft at Mainz (38).     

Freeman-Sheldon (whistling face) syndrome with hyperpyrexia in the newborn: case report

Freeman Sheldon syndrome (FSS) is a rare, multiple congenital contracture syndrome that is relatively well-known, since affected children have a striking appearance. This entity was historically referred to as the "whistling-face syndrome". Malignant hyperthermia and hyperpyrexia have been documented in FSS after general anesthesia related to the neuropathy. We report a male neonate with FSS and hyperpyrexia without anesthesia. To our knowledge, our patient is the first in the literature with hyperpyrexia in the newborn period without anesthesia.     

Accurate Prediction of Severe Allergic Reactions by a Small Set of Environmental Parameters (NDVI,Temperature)

Severe allergic reactions of unknown etiology,necessitating a hospital visit, have an important impact in the life of affected individuals and impose a major economic burden to societies. The prediction of clinically severe allergic reactions would be of great importance, but current attempts have been limited by the lack of a well-founded applicable methodology and the wide spatiotemporal distribution of allergic reactions. The valid prediction of severe allergies (and especially those needing hospital treatment) in a region, could alert health authorities and implicated individuals to take appropriate preemptive measures. In the present report we have collecterd visits for serious allergic reactions of unknown etiology from two major hospitals in the island of Crete, for two distinct time periods (validation and test sets). We have used the Normalized Difference Vegetation Index (NDVI), a satellite-based, freely available measurement, which is an indicator of live green vegetation at a given geographic area, and a set of meteorological data to develop a model capable of describing and predicting severe allergic reaction frequency. Our analysis has retained NDVI and temperature as accurate identifiers and predictors of increased hospital severe allergic reactions visits. Our approach may contribute towards the development of satellite-based modules, for the prediction of severe allergic reactions in specific, well-defined geographical areas. It could also probably be used for the prediction of other environment related diseases and conditions.     

PRODUCTS OF THE OXIDATION OF THIOSULFATE BY BACTERIA IN MINERAL MEDIA

Various cultures (previously described), which oxidize thiosulfate in mineral media have been studied in an attempt to determine the products of oxidation. The transformation of sodium thiosulfate by Cultures B, T, and K yields sodium tetrathionate and sodium hydroxide; secondary chemical reactions result in the accumulation of some tri- and pentathionates, sulfate, and elemental sulfur. As a result of the initial reaction, the pH increases; the secondary reactions cause a drop in pH after this initial rise. The primary reaction yields much less energy than the reactions effected by autotrophic bacteria. No significant amounts of assimilated organic carbon were detected in media supporting representatives of these cultures. It is concluded that they are heterotrophic bacteria. Th. novellus oxidizes sodium thiosulfate to sodium sulfate and sulfuric acid; the pH drops progressively with growth and oxidation. Carbon assimilation typical of autotrophic bacteria was detected; the ratio of sulfate-sulfur formed to carbon assimilated was 56:1. It is calculated that 5.1 per cent of the energy yielded by the oxidation of thiosulfate is accounted for in the organic cell substance synthesized from inorganic materials. This organism is a facultative autotroph. The products of oxidation of sodium thiosulfate by Th. thioparus are sodium sulfate, sulfuric acid, and elemental sulfur; the ratio of sulfate sulfur to elemental sulfur is 3 to 2. The pH decreases during growth and oxidation. The elemental sulfur is produced by the primary reaction and is not a product of secondary chemical changes. The bacterium synthesizes organic compounds from mineral substances during growth. The ratio of thiosulfate-sulfur oxidized to carbon assimilated was 125:1, with 4.7 per cent of the energy of oxidation recovered as organic cell substance. This bacterium is a strict autotroph.     

Direct in vivo monitoring of acute allergic reactions in human conjunctiva

Immediate allergic reactions are initiated by allergen-induced, specific IgE-mediated mast cell degranulation and involve leukocyte recruitment into the inflamed site. We compared conjunctival signs, symptoms, and in vivo leukocyte rolling and extravasation into sites of inflammation in five patients allergic to birch pollen and in 10 nonallergic controls who received a challenge to birch allergen or histamine. Both the specific allergen in allergic patients and histamine, both in patients and in healthy controls, induced symptoms and signs of an immediate allergic reaction together with leukocyte rolling within the conjunctival blood vessels. However, only allergen, not histamine, caused leukocyte extravasation into the site of inflammation in the allergic patients. Allergen also increased expression of endothelial P-selectin in conjunctival vessels and slowed the rolling of leukocytes which is required for their extravasation from blood circulation into the target tissue. Finally, i.v. heparin strongly reduced the number of slowly rolling cells during allergen- or histamine-induced reactions and this can probably hinder the leukocyte extravasation after allergen exposure. These findings suggest that slow rolling is required for leukocyte extravasation in acute allergic reactions, and it can be inhibited by heparin in vivo in therapeutically relevant conditions.     

Arterial blood gas tensions and acid-base status of Wistar rats during thiopental and halothane anesthesia.

Arterial blood gas tensions and acid-base status of spontaneously-breathing, unanesthetized Wister rats were compared with values obtained during 4 hr of thiopental and 6 hr of halothane (1%) anesthesia. During thiopental anesthesia, marked respiratory depression occurred (PaCO-2:57.0 plus or minus 10.0 MM Hg, PaO-2:70.4 plus or minus 11.2 MM Hg). Thirty-six percent of the rats died. During inhalation of room air and 1% halothane, PaO-2 decreased also, whereas PaO-2 did not change. Twenty-seven percent of the original number of rats died. Lowered arterial oxygen tension may have caused death; no rats died during inhalation of oxygen and 1% halothane. This technic insured sufficient analgesia for surgical procedures without marked alterations of the acid base status and is recommended for long-term anesthesia of small laboratory animals like rats.     

Effect of decomplemantation on the course of several allergic skin reactions]

Experiments were conducted on mongrel albino mice; a study was made of the role played by the complement in the development of passive skin anaphylaxis after Ovarie and the so called reverse direct allergic (cytotoxic) reaction. Preliminary animal decomplementation 3 hours before the reactions were conducted failed to alter the intensity of Ovarie reaction, and decreased the intensity of the reverse direct allergic reaction significantly. Reproduction of Ovarie reaction and of the reverse direct allergic reaction on animals 24 hours after the decomplementation did not influence the manifestation of both reactions.     

Maculopapular eruption secondary to itraconazole

Adverse cutaneous reactions to itraconazole are known to be quite rare. We report a case of maculopapular reaction caused by itraconazole. On the 7th day of itraconazole therapy for hand onychomycosis, in a 39-year-old woman pruritus occurred with a subsequent morbiliform, symmetric, maculopapular eruption on the upper torso, neck, trunk and pressure-bearing areas. Eruption progressed, becoming confluent and spreading to extremities. Due to increasing indications for the administration of itraconazole its increased usage as well as the possibility of allergic reactions should be expected even if these are a rare event.     

Secondary prevention of allergic symptoms in a dairy farmer by use of a milking robot

Background

Allergic sensitization and reactions to guinea pig (Cavia porcellus) have been well documented in laboratory animal handlers, primarily manifesting as rhinitis, conjunctivitis, and asthma. Severe allergic reactions, however, are rare.

Methods

We report two patients with severe allergic reactions following non-occupational exposure to guinea pigs. The first patient, an 11-year-old female, developed ocular, nasal, skin and laryngeal edema symptoms immediately after handling a guinea pig. The second patient, a 24-year-old female, developed symptoms of isolated laryngeal edema after cleaning a guinea pig cage. Percutaneous skin testing, RAST, ELISA and ELISA inhibition testing with guinea pig extract were performed.

Results

Both patients had IgE-mediated allergy to guinea pig confirmed by ELISA and either RAST or skin testing. ELISA inhibition studies confirmed the specificity of the IgE reactivity to guinea pig.

Conclusion

Severe IgE-mediated reactions can occur following non-occupational guinea pig exposure. Physicians should be aware of this possibility.     

Allergy to penicillin: fable or fact?

OBJECTIVE--To assess whether, on the basis of one blood test, penicillin allergy might be excluded sufficiently for general practitioners to give oral penicillin to patients claiming a history of penicillin allergy. DESIGN--Prospective study of patients referred by general practitioners. SETTING--Outpatient allergy clinic in a district general hospital. PATIENTS--175 referred patients who gave a history of immediate type reaction to penicillin, of whom 144 attended as requested and 132 completed the investigations. MAIN OUTCOME MEASURES--History and examination, serum radioallergosorbent test to phenoxymethylpenicillin and benzylpenicillin, and oral challenge with penicillin. RESULTS--Of 132 patients, four were confirmed to have penicillin allergy by the radioallergosorbent test and 128 had an oral penicillin challenge without ill effect. CONCLUSIONS--Most patients who gave a history of penicillin allergy are not so allergic, and their actual allergic state should be substantiated whenever feasible. For patients reporting minor or vague reactions negative findings with a radioallergosorbent test to phenoxymethylpenicillin and benzylpenicillin provide sufficient evidence to give oral penicillin safely.     

Effect of barbitone sodium and thiopental sodium on brain dopamine, noradrenaline, serotonin and 5-hydroxyindoleacetic acid content in Arvicanthis niloticus

The quantitative estimation of total dopamine (DA), noradrenaline (NE), serotonin (5-HT) and 5-hydroxyindoleacetic acid (5-HIAA) content in the whole brain tissue of normal Nile grass rat, Arvicanthis niloticus, gives and average of 631 +/- 12 ng DA/g, 366 +/- 12 ng NE/g, 617 +/- 15 ng 5-HT/g and 431 +/- 10 ng 5-HIAA/g fresh brain tissue. The effect of barbitone sodium and thiopental sodium on the total DA, NE, 5-HT and 5-HIAA content in the brain tissue of the Nile grass rat, Arvicanthis niloticus, was studied. The total DA, NE, 5-HT and 5-HIAA contents were determined 5 hr after i.p. injection of different doses of barbitone sodium (20, 40 and 80 mg/ml/100 g body wt) and thiopental sodium (5, 10 and 20 mg/ml/100 g body wt). The effect of different time intervals (1, 10, 30 min, 1, 2.5, 5, 8, 16, 24 and 48 hr) on the total brain DA, NE, 5-HT and 5-HIAA content was investigated after i.p. injection of 40 mg of barbitone sodium and 10 mg of thiopental sodium/ml/100 g body wt. Both barbitone sodium and thiopental sodium caused an increase in DA, NE and 5-HT content and a decrease in 5-HIAA content in the brain tissue of Arvicanthis niloticus. The increase in the whole brain contents of DA, NE and 5-HT after the administration of barbitone sodium and thiopental sodium may be due either to inhibition of transmitter release by an action at the monoamine nerve terminal or to effects causing a decrease in nerve impulse flow. On the other hand, the decrease in 5-HIAA may be due to the decrease in the turnover of 5-HT.