[Efficacy of repeated subcostal transversus abdominis plane blocks with 0.2% lidocaine via 18-gauge intravenous catheters for patients undergoing abdominal aortic aneurism surgery].

BACKGROUND: There is an increasing number of patients scheduled for abdominal aortic aneurysm resection in whom epidural anesthesia cannot be performed because of concomitant antiplatelet/anticoagulant therapy. Instead of epidural anesthesia for postoperative analgesia in such patients it is possible to use repeated bilateral subcostal transversus abdominis plane (TAP) blocks. METHODS: Four patients receiving antiplatelet/anticoagulant therapy for abdominal aortic aneurysm resection under general anesthesia were studied. After the completion of surgery and before emergence from anesthesia 18-gauge intravenous catheters were inserted bilaterally into subcostal TAP and 100 ml (50 ml on each side) of 0.2% lidocaine with 1/500,000 epinephrine were injected via the catheters twice daily until the second postoperative day. Pain intensity was assessed using a 0-10 numerical rating scale at rest and during movement, before and after each block. RESULTS: Numerical pain ratings at rest and during movement decreased after each block, and good analgesia was obtained. No complications such as nausea, vomiting or infection were observed in the postoperative period. CONCLUSIONS: These findings suggest that repeated bilateral subcostal TAP blocks with 0.2% lidocaine performed via 18-gauge intravenous catheters provide good postoperative analgesia after abdominal aortic aneurysm resection.

[Safety of axillary and subclavian vein cannulation using real-time ultrasound guidance].

BACKGROUND: The safety of real-time ultrasound-guided subclavian and axillary vein cannulation as opposed to ultrasound-guided internal jugular vein cannulation has not received much attention. We retrospectively compared the safety and value of real-time ultrasound-guided cannulation in the subclavian and axillary veins with those of the landmark method. METHODS: We divided 355 patients who had undergone central venous cannulation of the subclavian and axillary vein under local anesthesia into a group that had undergone real-time ultrasound-guided cannulation (Group U), and another group cannulated using the landmark method (Group L). We compared rates of complications and cannulation success as well as average procedural durations between the two groups. RESULTS: The complication rate was significantly lower in Group U (P=0.005). Most of the complications were arterial puncture. Five patients who developed pneumothorax and nerve damage were in Group L. The success rates and average procedural duration did not significantly differ. CONCLUSIONS: Real-time ultrasound-guided subclavian and axillary vein cannulation is associated with a low incidence of complications similar to that of the internal jugular vein when competent individuals with appropriate training apply the technique.

[Safety and beneficial effects of spinal morphine on the postoperative course of elderly patients undergoing surgical fixation of the femoral neck fracture].

BACKGROUND: We performed a retrospective study of the efficacy and safety of spinal anesthesia with 0.1 mg morphine in the postoperative course of elderly patients with femoral neck fracture. METHODS: Sixty patients with ages averaging 84 years participated in this study. Surgery was performed under spinal anesthesia. Patients were assigned to either a group receiving of 0.1 mg morphine added to isobaric bupivacaine (Group M) or a group receiving of isobaric bupivacaine alone (Group B). The frequency of analgesic use and the occurrence of adverse side effects during the first 48 hours after surgery were compared between the two groups. RESULTS: In the first 24 hours, the patients in Group M needed significantly less analgesics compared to Group B. The incidence of adverse side effects did not differ significantly between the groups, although nausea had a tendency to increase in Group M. One patient in Group M showed a mild decrease in oxygen saturation. CONCLUSIONS: The spinal administration of 0.1 mg morphine had beneficial effects and was safe in the postoperative period of elderly patients with femoral neck fracture provided that sufficient observation was given.

[Case of sublingual hematoma following difficult laryngoscopy in a patient on anticoagulant therapy].

A 61-year-old man receiving anticoagulant therapy after the aortic valve replacement underwent emergency surgery for acute appendicitis. Although the patient was intubated with difficulty, no immediate complications were evident after extubation. On the evening of the first postoperative day he complained of a sore throat, difficulty in swallowing and dysphonia. The swelling of the tongue with right-side predominance and the swelling of the right neck were observed. The right-sided sublingual hematoma was confirmed by CT. The symptoms improved with steroid administration. The possibility of airway obstruction due to hematoma of the tongue should be considered in patients on anticoagulant therapy.

[Massive hemorrhage during cesarean section for placenta accreta].

A 37-year-old multigravida presented at 37 weeks of gestation with low-lying placenta and highly suspected placenta accreta. The placenta adhered widely to the anterior wall of the uterus. Therefore, a longitudinal incision of the uterine corpus at the thinnest part of the placenta was made during surgery. Concurrent with the incision, rapid and massive hemorrhage occurred. After the delivery of the baby and confirmation of the placental adhesion, the hysterectomy was started promptly. The bladder adhered strongly to the uterus, and was injured during the dissection. The total volume of hemorrhage was estimated to be 24,480 ml (including amniotic fluid and urine). No arterial clamp for hemostasis was used during the procedure. The patient was discharged on the 12th postoperative day with no sequela. The pathological diagnosis was placenta percreta. Placenta accreta is a rare disease with a high mortality rate. The hemorrhage becomes difficult to control in case of injury of placenta accreta. The hysterectomy following cesarean section also becomes complicated. Bladder injury is one of the complications of the cesarean hysterectomy which makes the hemorrhage greader. In conclusion, when placenta accreta is suspected a strategy to minimize blood loss during surgery should be discussed by a multidisciplinary team.

[Internal jugular vein cannulation guided by ultrasonography in pediatric patients undergoing cardiovascular surgery].

BACKGROUND: Central venous catheterization is essential for the anesthetic management of operations for congenital heart diseases. We prospectively examined the usefulness of ultrasonography in internal jugular vein catheterization in infants. METHODS: Internal jugular vein cannulation was guided using an ultrasound image scanner in 96 pediatric cardiac patients. We investigated the rate of successful catheterizations, the number of attempts, the time from venipuncture to wire insertion, and the laterality of internal jugular vein diameters. RESULTS: The success rate in all 96 patients was 95.8% with no carotid artery puncture. Patients younger than 12 month of age had success rates of 90%. In patients younger than 1 month of age and with weights less than 3.4 kg, the success rate was 76.9%. The time from venipuncture to proper wire insertion in the first attempt (55.2%) was 50.8+/-18.9s; 157.3 +/-56.4s for second attempt (18.8%) ; 285.7+/-165.7s for third attempt (7.6%) ; 346.0+/-98.4s for fourth attempt (5.5%) : and 510.0+/-98.4s for fifth attempt (2.1%). The time requited was 1404.5+/-518.4s for attempts that required more than seven passes. Cannulations in four cases were unsuccessful because the image of the internal jugular vein was difficult to visualize. The left internal jugular vein diameter was larger than the right in 40 cases. In three unsuccessful cases, the diameter was less than 4.5 mm. CONCLUSIONS: Internal jugular vein cannulation guided by ultrasonography can be performed safely and quickly in pediatric patients.

Three-month exercise and weight loss program improves heart rate recovery in obese persons along with cardiopulmonary function.

OBJECTIVE: Heart rate recovery (HRR) after exercise is an independent risk factor for cardiovascular disease and mortality, and it is well known to be modifiable by weight loss. We investigated whether HRR was mainly improved by better cardiopulmonary function or by alteration of the metabolic profile. METHODS: The weight loss program included 2h of group exercise per week and individual dietary instruction by a qualified dietician every week. Clinical assessment (including HRR) was done before and after the 3-month program. PATIENTS: The subjects were 125 obese persons without a past history of stroke, cardiovascular events, or use of medications who participated in and completed our exercise plus weight loss program. RESULTS: HRR (35.61+/-12.83 to 45.34+/-13.6 beats/min, p<0.0001) was significantly faster after the program. The change in HRR was significantly correlated (p<0.05) with the changes in body weight, body mass index, percent body fat, waist circumference, hip circumference, resting heart rate, peak exercise heart rate, exercise time, maximal work load, physical working capacity divided by body weight (PWC75%HRmax/weight), subcutaneous fat area, visceral fat area, low-density lipoprotein cholesterol, and leptin. Multivariate analysis showed that the change in HRR was significantly correlated (p<0.05) with the changes in resting heart rate, peak exercise heart rate, and PWC75%HRmax/weight. CONCLUSIONS: Our data demonstrated that HRR can be improved in obese subjects by a 3-month exercise and weight loss program. Improvement in cardiopulmonary function by exercise seems to be the main contributor to the increment of HRR.

Effectiveness of a lumbar support continuous passive motion device in the prevention of low back pain during prolonged sitting.

STUDY DESIGN: Subjective ratings of discomfort were compared between a fixed lumbar support and lumbar support continuous passive motion (CPM) device. OBJECTIVE: To compare a fixed lumbar support with a lumbar support CPM device during prolonged sitting. SUMMARY OF BACKGROUND DATA: To prevent low back pain during prolonged sitting, an inflatable lumbar support CPM has been developed. There are no studies that compare static lumbar support with lumbar CPM using the same pressure in the cushions. METHODS: A total of 31 male volunteers without low back pain sat in the same chair for a 2-hour period on each of 3 consecutive days under 3 randomized test methods: 1, no lumbar support; 2, static lumbar support; and 3, lumbar support CPM. Each subject rated low back pain, stiffness, fatigue, and buttock numbness on a visual analog scale (VAS). Fixed lumbar support and CPM device were compared with a same inflation pressure in the cushion. For 10 subjects, the whole body posture and the pressure distribution changes of the human-seat interface during CPM were evaluated. RESULTS: Compared with no lumbar support, a significant improvement in VAS scores for low back pain, stiffness, and fatigue was obtained with both static lumbar support and with lumbar support CPM (P < 0.005). A significant (P < 0.005) improvement for buttock numbness was obtained only with lumbar support CPM. There were no statistical differences in all VAS scores between the fixed lumbar support and the CPM device. A forward rotation of the pelvic region was obtained during inflation of the cushion during CPM. Significant differences (P < 0.05) were found between cushion inflation and deflation periods both in contact areas and in the peak pressures at the human-seat interface. CONCLUSION: There were no statistical differences in the subjective ratings of discomfort between the fixed lumbar support and the CPM device.