Combination of topical EMLA with local injection of lidocaine: superior pain relief after Ferguson hemorrhoidectomy.

OBJECTIVE: To determine whether a combination of topical anesthetic (EMLA) and local injection with lidocaine is better than lidocaine alone for pain relief after Ferguson hemorrhoidectomy. METHODS: Sixty patients scheduled for hemorrhoidectomy were randomized into 2 groups: (1) control group (CG, n=30) received neomycin ointment (5 g), and (2) EMLA group (EG, n=30) received EMLA (5 g), both agents applied topically after surgery. Before the surgical incision was made, lidocaine (10 mL of a 1% solution) was locally injected into all 60 patients. After surgery, analgesics were provided when necessary. The visual analog scale score was recorded at 4 time points: (1) upon arrival in the postanesthesia room, (2) 2 hours after arriving in the postanesthesia room, (3) between 9 and 10 PM on the first postoperative evening, and (4) on the first postoperative morning. The frequency of meperidine requests, 1-time catheterizations for urinary retention, and patient satisfaction with postoperative pain management, were also recorded. RESULTS: The median visual analog scale scores and cumulative dosages of meperidine were significantly lower in the EG than the CG (P<0.05). Patient satisfaction with postoperative pain control was also significantly higher in the EG than the CG (P<0.01). No systemic complications occurred. DISCUSSION: EMLA is considered a breakthrough in cutaneous analgesia, capable of reducing pain in many cutaneous procedures. Because Ferguson hemorrhoidectomy has been performed for years with ongoing concerns over postoperative pain, we felt that using EMLA could lower postoperative pain intensity and the number of requests for additional medication.

Earlier cessation of desflurane supply in closed-circuit anesthesia reduces emergence time in patients undergoing breast surgery.

BACKGROUND: Minimizing the time of anesthesia emergence can facilitate faster patient turnover in the operating rooms of a busy surgery center. According to Lin's new concept of inhalation uptake, after turning off the vaporizer under close-circuit anesthesia (CCA) with a very low fresh gas flow rate, the concentration of desflurane decreases at a slow rate. The aim of this study was to determine if earlier cessation of desflurane supply would shorten the emergence time and at the same time register the changes of desflurane concentration in the circuit after turning off the vaporizer. METHODS: 30 patients were randomly assigned to two groups, i.e., the control group and the study group. In the control group, the desflurane supply was continued up till the end of the operation, while in the study group the desflurane supply was cut off prior to the suturing the skin. In the study group, data regarding the hemodynamic changes, time from turning off desflurane with high flow washout to wakefulness, and the inspired as well as the expired desflurane concentrations at the low-flow anesthetic phase were collected. The time required from high flow washout to emergence was recorded in all patients. Inter-group and intra-group data were analyzed with nonparametric 2-independent-samples Mann-Whitney test and 2 related-samples Wilcoxon signed ranks test, respectively. RESULTS: Under CCA with similar surgical duration, the patients in the study group emerged from anesthesia significantly faster than those in the control group (5.6 +/- 1.9 min versus 8.8 +/- 2.3 min; P < 0.05), without molestation of stable hemodynamic signs. At the low-flow wash-in stage, the inspired desflurane concentrations were significantly higher than the expired ones from 0 to 2nd min; no significant difference was noted from the 3rd to 6th min, but after which the expired concentrations were significantly higher. Desflurane concentrations decreased most noticeably during the first 5 min (0.35 +/- 0.14%), and then the decrease was moderating from 6th to 10th min (0.21 +/- 0.58%) and staggered from 11th to 15th (0.14 +/- 0.06%). The mean duration of low flow wash was 25.6 +/- 11.6 min. No patient reported awareness during surgery. CONCLUSIONS: Ceasing desflurane supply earlier in CCA (250 mL/min) significantly shortens emergence time without significant hemodynamic changes.

Fiberoptic tracheal intubation through a classicial laryngeal mask airway under spontaneous ventilation in a child with Treacher Collins syndrome.

This report cites the usefulness of fiberoptic scope-guided endotracheal tube intubation through a classical laryngeal mask airway (LMA) during spontaneous breathing. Treacher Collins Syndrome (TCS) is a condition where airway management is stressful to anesthesiologists. We report a pediatric patient with TCS undergoing cleft palate repair. The patient had a history of sleep apnea syndrome, chronic lung disease, and congenital heart disease. Intubation by rigid laryngoscopy was unsuccessful at the first attempt. One month later, under spontaneous ventilation, tracheal intubation was smoothly performed with the use of a fiberoptic scope through an LMA under intravenous anesthesia with propofol. Fiberoptic scope-guided endotracheal intubation through an LMA with the push of another ETT of the same size to curb the back slippage of the endotracheal tube already inserted in the trachea can be easily and safely performed under spontaneous breathing in a pediatric patient with TCS.

Intrathecal midazolam combined with low-dose bupivacaine improves postoperative recovery in diabetic mellitus patients undergoing foot debridement.

BACKGROUND: Intrathecal midazolam acts synergically with other anesthetics to relieve surgical pain, and the drug combination may decrease complications attributable to each component drug. This prospective study was to determine the spinal effects of low-dose of bupivacaine (5 mg) combined with intrathecal midazolam (2 mg) in diabetes mellitus (DM) patients undergoing foot debridement. METHODS: Sixty diabetic patients were admitted for foot debridement under spinal anesthesia were equally divided into two groups. Group 1 (M) received 7.5 mg of hyperbaric bupivacaine; group 2 (M+M) received 5 mg of hyperbaric bupivacaine combined with 2 mg of midazolam intrathecally. The intensity of motor block was assessed with modified Bromage scale 20 minutes after injection, and at 0, 30, 60, 90 and 120 min after arriving at the post anesthesia care unit (PACU). Pain score was assessed with a 10 cm visual analog scale (VAS, 0 = no pain and 10 = intolerable pain) at 0, 1, 2, 6 h and 24 h postoperatively. RESULTS: Anesthesia was smooth in all patients except one in group M, whose analgesia was inadequate and general anesthesia was given to complete the surgery. The number of patients who sustained moderate to severe pain (VAS > 5) was significantly less in the M+M group than in M group as accessed 6 and 24 h postoperatively. The requirement of additional analgesic as reinforcement was significantly less in the M+M group than in the M group within the space of 24 h postoperatively. Recovery of motor function was significantly faster in the M+M group. CONCLUSIONS: The combination of intrathecal midazolam and bupivacaine was a safe and effective anesthetic technique, and it also provided early recovery of motor function and reduced the requirement of analgesics postoperatively.