Catastrophic complication of an interscalene catheter for continuous peripheral nerve block analgesia.

We report a catastrophic postoperative complication of a prolonged interscalene block performed under general anaesthesia. The course of the anaesthetic was uneventful and the patient remained stable during his stay in the recovery area with the operative extremity paralysed and insensate. No further local anaesthetic was administered until later that day when the patient received 10 ml bupivacaine 0.25% through the catheter. Upon completion of the top-up dose, no change in the patient's status was noticed. The patient was next assessed 6.5 h later when he was found dead in his bed. A postmortem CT scan revealed the catheter to be sited intrathecally, presumably the result of dural sleeve penetration.

The Combitube in elective surgery: a report of 200 cases.

BACKGROUND: The Combitube has proved to be a valuable device for securing the airway in cases of difficult intubation. This study investigated the effectiveness of the Combitube in elective surgery during both mechanical and spontaneous ventilation. METHODS: Two hundred patients classified as American Society of Anesthesiologists physical status I and II, with normal airways, scheduled for elective surgery were randomly allocated into two groups: nonparalyzed, spontaneously breathing (n = 100); or paralyzed, mechanically ventilated (n = 100). After induction of general anesthesia and insertion of the Combitube, oxygen saturation, end-tidal carbon dioxide and isoflurane concentration, systolic and diastolic blood pressure and heart rate, as well as breath-by-breath spirometry data were obtained every 5 min. RESULTS: In 97% of patients, it was possible to maintain oxygenation, ventilation, and respiratory mechanics, as well as hemodynamic stability during either mechanical or spontaneous ventilation for the entire duration of surgery. The duration of surgery was between 15 and 155 min. CONCLUSIONS: The results of this study suggest that the Combitube is an effective and safe airway device for continued management of the airway in 97% of elective surgery cases.

Does the addition of fentanyl to bupivacaine in caudal epidural block have an effect on the plasma level of catecholamines in children?

We evaluated the effect of adding fentanyl to bupivacaine, compared with bupivacaine alone, on the stress response. The effect was evaluated by determining blood levels of epinephrine (E) and norepinephrine (NE) in pediatric patients receiving caudal epidural blocks. Sixty children, 1-8 yr of age, scheduled for elective herniorrhaphy, were randomly allocated to two groups of 30 patients each. Group A received inhaled anesthesia and caudal epidural block with bupivacaine 0.25% alone, 1.0 mL/kg. Group B received identical anesthesia; however, fentanyl 1 microg/kg was added to the bupivacaine in the caudal block. Blood samples for E and NE plasma levels were drawn at induction time (H(0)), at the end of surgery (H(1)), and in the postanesthesia care unit (H(2)). In both groups, there was a significant decrease in the E and NE plasma levels, when comparing H(1) and H(2) with H(0) within the same group (P < 0.001). There were no significant differences in the E and NE plasma levels between the two groups at H(0), H(1), and H(2) (P = 0.5, P = 0.12, P = 0.5, respectively). Pain scores (modified Children's Hospital of Eastern Ontario Pain Score) were also similar in both groups (P = 0. 19). This study suggests that adding fentanyl 1 microg/kg to bupivacaine in the caudal epidural block in children does not influence plasma levels of E and NE, nor does it improve the analgesic intensity of the caudal block.

Using rate-based events to improve clinical practice.

This article describes the implementation and utilization of a continuous quality improvement (CQI) program in the identification, analysis, and correction of a rate-based event in anesthesia, in this case, intraoperative hypertension. A CQI program was implemented based on voluntary, handwritten, anonymous reports of intraoperative and postanesthesia care unit events. This CQI program detected a high incidence of intraoperative hypertension, indicated major causal factors, suggested a set of corrective measures, and allowed for measurement of their efficacy.

Replacing the combitube by an endotracheal tube using a fibre-optic bronchoscope during spontaneous ventilation.

We present a case of microlaryngoscopy in a patient with an unexpectedly difficult airway. The airway was managed by using an oesophageal-tracheal Combitube (Kendall-Sheridan, Argyle, NY) (ETC) and a fibre-optic bronchoscope (Pentax-Japan-5 mm).

The influence of patient positioning on the hemodynamic changes in TURP patients with severe coronary disease.

Hemodynamic changes were studied in 10 patients with severe coronary disease during routine transurethral prostatectomy (TURP) when performed in the lithotomy position with and without elevation of the legs. The patients undergoing the procedure in the lithotomy position with elevation of the legs exhibited significant hemodynamic changes as compared with those undergoing the procedure without elevation of the legs. This leads us to conclude that performing TURP in the lithotomy position without elevation of the legs benefited the patient by stabilizing hemodynamic factors.