Probable cervical midline epidural septum complicating the treatment of a patient with upper extremity sympathetically maintained pain.

We present a woman who developed left arm sympathetically maintained pain (SMP, or "shoulder-hand syndrome") as a result of brachial plexus injury. After confirmatory diagnosis with both stellate local anesthetic block and intravenous phentolamine infusion, the patient had a cervical epidural catheter placed and a local anesthetic infusion started. After numerous unilateral blocks were obtained, a cervical epidurogram demonstrated a probable cervical midline epidural septum. Catheter placement was adjusted, and a successful chemical sympathectomy was performed for 6 days. This resulted in significant relief of the patient's shoulder pain as well as almost complete resolution of the patient's left arm SMP symptoms. This case represents, to our knowledge, the first documentation of the use of phentolamine for the diagnosis of SMP secondary to pathology at a site proximal to that of symptomatology, as well as the first documentation of presumptive cervical midline epidural septum.

Relief of recurrent upper extremity sympathetically-maintained pain with contralateral sympathetic blocks: evidence for crossover sympathetic innervation?

A case of recurrent right upper extremity sympathetically maintained pain was completely relieved with contralateral sympathetic blocks. Yet Ipsilateral blocks produced no change in pain. Surgical sympathectomy of the contralateral thoracic sympathetic chain produced significant and persistent pain relief. This case, to our knowledge the first such reported, raises questions regarding the accepted sympathetic innervation of the upper extremity.

Reflex sympathetic dystrophy.

In summary, RSD is pain of neuropathic origin. The diagnosis is often obscure and requires a complete history, physical, and psychological evaluations. The diagnosis depends on symptoms (burning pain, allodynia and hyperpathia); signs (edema, sudomotor changes, temperature changes); and objective measurements, such as skin temperature, QSART, radiographs, and triple-phase bone scans; as well as the clinical response to a sympathetic block. Management of RSD should be designed to promote restoration of function utilizing physical therapy made possible by sympathetic, central, or peripheral nerve blockade. Medications may include nonsteroidal anti-inflammatory drugs, tricyclic antidepressants, and vasoactive drugs. Psychologic support is an important part of the patient's rehabilitation. Dorsal column or peripheral nerve stimulators, sympathectomies, and narcotics should be considered only when other more conservative measures have failed.

Epidemiology of extra-pulmonary tuberculosis in the United States: high rates persist in the post-HIV era.

BACKGROUND: The incidence of tuberculosis (TB) in the United States has declined following a logarithmic pattern, with few exceptions. One exception was during the acquired immunodeficiency syndrome (AIDS) epidemic, which was thought to have caused the deviation. However, since then, alternative explanations have been proposed, including the increased burden of chronic diseases, immigration, and the increase in the use of immune suppressant medications. METHODS: Epidemiological data of the Center for Disease Control and Prevention (CDC) and the Bureau of the Census were analyzed regarding TB incidence, human immunodeficiency virus (HIV) infection, immigration status, and age for the period 1953-2011. RESULTS: Data analysis identified a deviation from the logarithmic decline in TB cases that started in the mid-2000s. This divergence did not appear to be related to HIV status. The overall decline in TB cases since 1953 has been almost exclusively due to a reduction in pulmonary TB (PTB) and not to extra-pulmonary TB (EPTB). CONCLUSIONS: The HIV/AIDS epidemic likely played a significant role in the 1979-1985 deviation, but not subsequently. Furthermore, EPTB as a proportion of total TB cases has remained high. Further studies to delineate the etiologies of these findings are needed.

Use of glycopyrrolate to treat intraoperative penile erection. Case report and review of the literature.

BACKGROUND AND OBJECTIVES: Penile erections following the initiation of either axial regional or general anesthesia is rare; however, when it occurs in patients undergoing urologic procedures it may delay, or even cancel, the planned surgery. The purpose of this case report and review is to enhance anesthesiologists' understanding of this phenomenon so that they may better formulate a logical treatment scheme in such an event. METHODS: We present a case of intraoperative erection after the initiation of continuous spinal anesthesia that was treated with intravenous glycopyrrolate. From the literature, 72 references were reviewed. RESULTS: Glycopyrrolate successfully treated intraoperative penile erection. The physiology and pharmacology of erection are reviewed, and pharmacologic treatment options and surgical treatments are reviewed. CONCLUSIONS: In patients with coronary artery disease, or in situations where cardiovascular stability is desired, glycopyrrolate is an effective means of relieving intraoperative penile erections. Other pharmacologic interventions, based on the physiology of erections, are presented. Nitric oxide, a potent smooth muscle relaxant, has been shown to be involved in the initiation and maintenance of erections; future research involving specific inhibitors of this chemical is indicated for the possible treatment of intraoperative penile erections.

The use of pressure support ventilation in the operating room.

Pressure support ventilation is used in intensive care units to improve patient-ventilator synchrony and facilitate weaning. An anesthesia machine that employs this mode of ventilation can now be used to allow smooth inductions, emergence, and maintenance of anesthesia while the patient is mechanically ventilated.

Peroral pharyngeal block for placement of esophageal endoprostheses.

BACKGROUND AND OBJECTIVES: The placement of plastic peroral endoprostheses frequently is done in the United States as a palliation for esophageal cancer. However, the combination of topical local anesthetics and sedatives, the most commonly used means to achieve anesthesia, can cause complications and often does not adequately suppress the gag reflex. The purpose of this study was to compare sedation requirements in patients receiving the standard topical local anesthetic versus patients receiving peroral pharyngeal plexus block. METHODS: From December 1987 through April 1991, 11 patients underwent endoscopic esophageal stent placement. The first six patients received topical 10% lidocaine spray, the other five patients received pharyngeal plexus blocks. Supplemental sedation was given until the patient closed their eyes but were responsive to verbal stimuli. Completeness of block was evaluated by stimulating the posterior oropharynx. Total sedative requirements were recorded for each patient. RESULTS: Patients receiving pharyngeal plexus block had profound anesthesia and suppression of the gag reflex, as determined by examination and the patient's tolerance of the procedure. Patients receiving only topical anesthesia and intravenous sedation tolerated the procedure poorly and required a greater amount of intravenous sedation than those in the blocked group (p less than 0.01). There were no anesthetic complications in patients receiving pharyngeal blocks. CONCLUSIONS: Our experience indicates that the endoscopic placement of esophageal endoprostheses is optimally performed with the aid of pharyngeal plexus block. This block provides profound anesthesia with minimal risk in debilitated, high-risk patients. The neuroanatomy of the oropharynx is also reviewed.

Quantitative testing of sympathetic function with laser Doppler flowmetry.

OBJECTIVE: The objective of this study was to develop an indirect technique for evaluating dynamic changes in sympathetic function in humans. METHODS: We used laser Doppler to monitor sympathetic mediated vasoconstrictive responses (VRs) produced by 3 different provocative stimuli: 4-second inspiratory gasp (IG), ice-water immersion (Ice), and a spring-loaded pin prick (Pin). Skin perfusion on the thenar eminence was continuously monitored in 10 normal subjects (aged 25 to 36 years) using laser Doppler. Ten trials of the 3 stimuli were presented to each subject at 1-minute intervals. We determined the VR, the percent decrease in perfusion produced by each stimulus, and the 2 standard deviation variation in perfusion. RESULTS: No subject found the IG maneuver uncomfortable. In contrast, the Pin and Ice stimuli were reported to be uncomfortable by 8 and 10 subjects, respectively. Five subjects found Pin and Ice stimuli overtly painful. Vasoconstrictive response was 54.1 +/- 2.3% (mean +/- SEM) with IG, 49.2 +/- 2.0% with Ice, and 24.0 +/- 1.8% with Pin. Baseline variation was approximately 15% in all trials. CONCLUSION: Inspiratory gasp vasoconstrictive response (IGVR) is a sensitive indirect technique for evaluating sympathetic efferent function. We observed that the magnitude of the VR elicited by the IG stimuli was similar to that induced by cold water. Unlike the VR induced by Pin or Ice, IGVR is not dependent on noxious input via somatic afferents; therefore, it can be used in patients with diseases that produce a peripheral neuropathy, such as diabetes mellitus. Present uses of this technique and speculation on future uses are presented.

Effects of neurolytic concentrations of alcohol and phenol on Dacron and Gore-Tex vascular prosthetic grafts.

BACKGROUND AND OBJECTIVES: Neurolytic nerve block, using either alcohol (A) or phenol (P), is frequently used to treat intractable pain. However, these agents may disrupt the integrity of prosthetic vascular grafts. To investigate this possibility, the tensile strength of Dacron (Meadox Medicals, Oakland, NJ) and Gore-Tex (W.L. Gore Associates, Flagstaff, AZ) vascular grafts was determined after in vitro exposure to various clinically used concentrations of A or P. METHODS: Segments of Dacron and Gore-Tex graft were placed in the following solutions: saline (S), 6% and 9% P, and 25%, 50%, 75%, and 100% A, and stored at 23 degrees +/- 1 degree C for 72 hours. Axial maximum load (in kilonewtons, KN) and strain (in mm/mm) were determined with an Instron universal testing machine (Instron Corporation, Camden, MA). Samples from the S, 9% P, and the 100% A groups were evaluated using a scanning electron microscope. RESULTS: Dacron tensile strength decreased a maximum of 23% after exposure to 50%, 75%, and 100% A. Dacron strain capacity decreased after exposure to A (50%, 75%, 100%) and P (6%, 9%). Scanning electron microscope of both P and A showed significant degradation. No changes were found in the Gore-Tex group after exposure to P or A, however, scanning electron microscope of the 100% A sample showed moderate fiber degradation. CONCLUSIONS: The study shows that Dacron woven grafts are degraded by concentrations of A of at least 50%, and to a lesser extent, concentrations of at least 6%, while Gore-Tex had only minimal changes. While neurolytic block offers distinct advantages in patients with terminal cancer pain, the findings suggest that the use of more conservative modalities, such as oral medication regimens, be considered for the treatment of intractable pain in patients with vascular prosthetic grafts that are proximate to the proposed site of neurolysis.

Effects of epidural test dose volume on skin perfusion, temperature, and reflex vasoconstriction.

BACKGROUND AND OBJECTIVES: The authors sought to define the effects of differing volumes of epidural test dose on skin perfusion, skin temperature, and reflex vasoconstriction to a maximal inspiration (inspiratory gasp vasoconstrictive response, IGVR). METHODS: With informed consent and Institutional Review Board approval, the authors studied 40 patients undergoing epidural anesthesia. Skin perfusion was monitored in glabrous skin on the foot using laser Doppler. Inspiratory gasp vasoconstrictive response and temperature measurements were obtained at 1-minute intervals. After a baseline period, 5 patients received 60 mg intravenous lidocaine HCl; 5 received 5 mL normal saline, via epidural catheter; and 30 patients received 50 mg lidocaine HCl and 20 mcg epinephrine in 2.5, 5.0, or 7.5 mL normal saline (10 patients each). Inspiratory gasp vasoconstrictive response was defined as the percent change in perfusion from baseline produced by an inspiratory gasp. Perfusion was normalized by expressing each patient's value as a percentage of the respective baseline value. RESULTS: Significant increases in perfusion, of up to 169% of baseline, were seen 12 minutes after the test dose. Inspiratory gasp vasoconstrictive response showed significant changes from baseline in all test groups. The temperature change was insignificant. Control groups did not show perfusion or IGVR changes. CONCLUSIONS: Skin perfusion and IGVR changed significantly after epidural test dose; the minimal effect of volume appears to be 5 mL of lidocaine-epinephrine solution; the presence of IGVR or perfusion changes, or both, are positive predictors of successful placement of the catheter into the epidural space; and temperature changes as observed here were not reliable predictors of proper placement of epidural catheters.

Time course of sympathetic blockade during epidural anesthesia: laser Doppler flowmetry studies of regional skin perfusion.

We studied the time course of sensory and sympathetic blockade in response to epidural local anesthetic test and bolus doses in 11 patients. Sympathetic activity was measured by monitoring cutaneous perfusion in the foot and the reflex vasoconstrictive response to deep inspiration (IGVR) using laser Doppler flowmetry. Sensory tests included the detection of touch, cold and painful stimuli. Following the 3-mL test dose perfusion increased to 192 +/- 38% (mean +/- SEM) of baseline (P < 0.05) in the patients with successful epidural anesthesia (9 of 11). In 8 of these patients, IGVR decreased to 73 +/- 10% of baseline (P < 0.05) within 6 min of the test dose, and preceded changes in sensation to cold, pin-prick, and light touch by 3.8 +/- 3.5 min (P < 0.2), 9.6 +/- 3.1 min (P < 0.01), and 11.6 +/- 2.7 min (P < 0.01), respectively. Five control patients who received only 60 mg of lidocaine intravenously and the two patients with failed epidurals did not show any perfusion or IGVR changes. This study confirms that sympathetic block precedes sensory block in sacral dermatomes after epidural anesthesia. Perfusion and IGVR changes are sensitive measures of sympathetic blockade and may predict successful epidural catheter placement.