Acta anaesthesiologica Sinica最新文献

With advanced knowledge of management of hydrocephalus, patients with ventriculoperitoneal shunts are expected to enjoy a longer lifetime. Developments in both instrumentations and surgical techniques have led to increasing popularity of laparoscopic surgery in many surgical subspecialties. Therefore, it is not a surprising event that a patient with a ventriculoperitoneal shunt is scheduled for a laparoscopic surgery under anesthesia. Until now, there is no uniformized protocol for anesthetic management of a patient with a ventriculoperitoneal shunt undergoing laparoscopic surgery. Increased intracranial pressure may occur intraoperatively and be a major concern. We report here our experience in anesthetic management of such a patient and discuss the anesthetic considerations and the potential complications.

Background: Providing dental care to a mentally handicapped patient is a challenge to both dentist and anesthesiologist. This study was aimed to describe the anesthetic methods which were used to facilitate dental treatments in mentally handicapped patients at a medical university hospital in Taiwan during a three-year period.

Methods: The data referring to anesthetic techniques to facilitate dental treatments during the period from Dec. 1, 1997 to Nov. 30, 2000 were retrospectively collected. In the period, there were four different anesthetic techniques in application: nasal mask technique combined with intravenous sedation, total intravenous anesthesia, laryngeal mask intubating general anesthesia and endotracheal intubating general anesthesia. Basic characteristics of patients were compared with student t-test between groups according to anesthetic technique used. Intraoperative and postoperative complications and complaints collected were analyzed by chi-square test between anesthetic techniques. P value less than 0.05 was considered statistically significant.

Results: The anesthetic records of 1201 mentally handicapped patients who underwent dental procedures over the three-year period were reviewed. Anesthesia was accomplished with nasal mask technique combined with intravenous sedation in 10 patients, with intravenous anesthesia in 112 patients, with endotracheal intubation anesthesia in 249 patients and with reinforced laryngeal mask anesthesia in 826 patients. Four patients were excluded from study because of changing of anesthetic method during the dental procedure. The use of nasal mask combined with intravenous sedation and intravenous anesthesia caused a higher incidence of intraoperative hypoxemia (P < 0.05) in comparison with the groups of endotracheal intubation anesthesia and reinforced laryngeal mask anesthesia. Although patients anesthetized by intravenous anesthetics had less postoperative complaints or complications but the difference was not statistically significant (P > 0.05) when group comparison was made. Patients who were anesthetized by volatile agents through endotracheal tube had the highest rate of postoperative complication although the difference was of no significance (P > 0.05) when comparison between groups was made.

Conclusions: We provided four different anesthetic methods for 1197 mentally handicapped patients who underwent dental procedures in three years. All anesthetic methods had their advantages and disadvantages. Using reinforced laryngeal mask or endotracheal intubation for general anesthesia to facilitate dental procedures for such patients had greater intraoperative safety than other two methods. However, less postoperative complaints or complications were revealed with the methods of nasal mask combined with intravenous sedation and intravenous anesthesia.

Burns associated with chemical disinfectants for skin preparation are rare. Skin irritation and maceration associated with pressure factors may contribute to its occurrence. We report a 24-year-old female with thyroid tumor who was admitted for subtotal thyroidectomy. After anesthetic induction, the patient was placed in the supine position with the trunk elevated to 20 degree. The skin over the anterior neck was sterilized with 10% Povidone-iodine (PI) alcohol solution. After a 3-hour surgery, the patient complained of burning pain over the back at the recovery room. Physical examination revealed a 9 x 11 cm area of skin lesion partially thickened amid on the middle of the back suggestive of chemical burn. After conservative treatment, she was discharged uneventfully 4 days later. Upon follow-up, the wound was seen to heal with minimal scarring within 3 weeks.

Background: Volatile anesthetics are known to potentiate the neuromuscular blocking effect of nondepolarizing muscle relaxants. The influences of anesthetic techniques, closed-circuit anesthesia (CCA) and high flow semi-closed anesthesia (SCA), on the neuromuscular blockade of rocuronium has not yet been studied in detail. This study was purposed to compare the effects of isoflurane conveyed in minimal flow (CCA) and in high flow (SCA) on the neuromuscular blockade of rocuronium.

Methods: Fifty females scheduled for elective laparoscopic gynecological surgery were enrolled for study and randomly assigned to receive either CCA (n = 25) or SCA (n = 25). Anesthesia was induced with fentanyl 2 micrograms/kg, thiopental 5 mg/kg and rocuronium 0.6 mg/kg. Two percent isoflurane in high O2 flow (3 l/min) was given for 10 min to all patients initially to wash isoflurane in the functional residual capacity of both lungs and the breathing circuit. After the wash in, for CCA group, the O2 flow was reduced to 300 ml/min with isoflurane vaporizer setting adjusted to 3-5% for anesthesia maintenance, while for SCA group, anesthesia was maintained with 1.5-2% isoflurane in 3 l/min O2 flow throughout the surgery. Electromyogram was used to determine neuromuscular blockade. Rocuronium (0.15 mg/kg) was given to maintain muscle relaxation when T1 reached 25% of control. We maintained the anesthetic depth until the recordings of T1 twitch response which reached 75% was completed. Onset time, duration, recovery index and intubating conditions were recorded. The hemodynamic parameters and the inhaled/exhaled concentrations were also measured every 15 min after skin incision in both groups.

Results: The onset time and intubating conditions were similar in both groups. In comparison with SCA group, longer clinical durations (54.1 +/- 14.4 vs. 45.4 +/- 9.2 min, P < 0.05), longer durations of maintained dose (41.1 +/- 11.1 vs. 30.2 +/- 8.6 min, P < 0.01) and longer recovery index (34.2 +/- 10.7 vs. 20.9 +/- 5.4 min, P < 0.0001) were observed in CCA group.

Conclusions: We conclude that CCA may further prolong the neuromuscular blocking effect of rocuronium than SCA.

A 62 year-old man sustained esophageal perforation following intra-operative transesophageal echocardiography (TEE) in a valvular replacement surgery. Septic shock developed on the 12th postoperative day (POD) and the esophageal perforation was diagnosed with chest CT. Emergent operation together with intensive care saved the patient's life. We speculate that the mechanism of perforation was not due to manipulation of the probe, but rather due to ischemia of the esophagus resulting from the combination of probe compression, non-pulsatile flow and the distension of the atria during a lengthy procedure. It is advisable that in patients with operative risk factors, such as distension of atria, long cardiac procedure and likely ischemia of organs due to cardiopulmonary bypass, the monitoring probe of TEE should not constantly rest in the esophagus and be withdrawn when it is idle or not in actual use. In addition, if resistance has been met during the intraoperative manipulation of the probe in a patient without previous history of esophageal disease, perforation might suspected if he or she sustains postoperative fever with positive chest X-ray findings.