Anesthesia for surgery related to Klippel-Trenaunay syndrome: a review of 136 anesthetics.

BACKGROUND: Klippel-Trenaunay syndrome (KTS) is a rare congenital malformation characterized by the triad of varicose veins or venous malformations, capillary malformations that may involve neurovascular structures, and bony or soft tissue hypertrophy in affected limbs. Areas such as the trunk, bowel, bladder, and spinal cord may be involved as well. KTS should not be confused with Klippel-Feil syndrome, which involves abnormalities of the cervical vertebrae. Anesthetic management for patients with KTS has only been described in limited case reports that caution about potential airway difficulty but do not report surgical hemorrhage requiring transfusion. METHODS: We performed an electronic search of the Mayo Clinic medical record database to identify patients who had undergone an anesthetic for surgery related to KTS. Review of medical records was performed for type of surgery, anesthetic technique, airway management and difficulty, medications used, intraoperative fluid administration, transfusion requirements, vascular access used, and postoperative complications. RESULTS: Eighty-two unique patients were identified who underwent 134 general anesthetics and 2 lumbar neuraxial anesthetics for surgeries related to KTS. Preoperatively, 27% of patients had a history of recurrent bleeding, 24% recurrent cellulitis, 9% deep vein thrombosis, and 2% pulmonary embolism. The mean age at time of surgery was 21 ± 15 years. The majority of surgical procedures involved laser coagulation or varicose vein sclerotherapy or stripping. All of the 74 direct laryngoscopies and tracheal intubations were performed on the first attempt without difficulty. Mask ventilation was possible in all 131 patients for whom this was attempted, with only 1 requiring an oral airway. Documented estimated blood loss ranged from 20 to 18,000 mL, with a mean of 740 ± 2739 mL. Use of a tourniquet did not obviate the possibility of substantial blood loss. The only significant postoperative complication involved a calf hematoma after vein stripping and avulsion that required return to the operating room for evacuation. CONCLUSIONS: Patients with KTS have multiple associated comorbidities relevant to perioperative management. In contrast to previous reports, difficulty with airway management was not encountered. Surgery related to severe KTS may be associated with massive hemorrhage despite tourniquet use, and the anesthesiologist should anticipate the need for appropriate fluid resuscitation. Neuraxial techniques may be considered only if the possibility of trauma to neurovascular malformations has been excluded with recent spine imaging.

Regional blockade in patients with a history of a seizure disorder.

BACKGROUND: Systemic local anesthetic toxicity is a potential complication in patients undergoing regional anesthesia, particularly during procedures requiring large doses of local anesthetic, such as epidurals, caudals, and peripheral nerve blocks. It is unknown whether patients with a history of a seizure disorder are at an increased risk of central nervous system toxicity (seizures) after local anesthetic administration. METHODS: We retrospectively reviewed the medical records of all patients with documented history of a seizure disorder who underwent epidural, caudal, or peripheral nerve block from January 1, 1988 to December 31, 2001. Patient demographics, character of the seizure disorder, details of the regional procedure, and seizure activity in the perioperative period were recorded. The rate of seizure due to local anesthetic toxicity per 10,000 anesthetics was estimated using a point estimate and corresponding 95% confidence interval (CI). RESULTS: During the 14-yr study period, 411 procedures in 335 patients with a seizure disorder were identified. Twenty-four patients experienced postoperative seizure activity. The timing of the most recent (preoperative) seizure was found to be significantly related to the likelihood of experiencing a postoperative seizure (P < 0.001). Based on the extended time interval between local anesthetic injection and/or termination of the infusion and the event, it was determined that the regional anesthetic was neither the primary etiology nor a contributing factor for the seizure in 19 of the 24 patients. In the remaining five patients, perioperative seizure activity was characteristic of their usual seizures. Although unlikely to be the cause of the seizure, local anesthetic toxicity could not be absolutely excluded as a contributing factor to the event in these five patients. Assuming that none of the seizures was related to local anesthetic toxicity the estimated incidence is 0 per 10,000 (95% CI 0-89 per 10,000). Conversely, if the seizures were related to local anesthetic toxicity in the five cases, the incidence is increased to 120 per 10,000 (95% CI 40-280 per 10,000). CONCLUSIONS: We conclude that majority of seizures occurring in the perioperative period in patients with a preexisting seizure disorder are likely related to the patient's underlying condition and that regional anesthesia in these patients is not contraindicated. Furthermore, because the likelihood of a postoperative seizure is increased in patients with a recent seizure, it is essential to be prepared to treat seizure activity, regardless of the anesthetic and analgesic technique.

Effect of neurolytic celiac plexus block on pain relief, quality of life, and survival in patients with unresectable pancreatic cancer: a randomized controlled trial.

CONTEXT: Pancreatic cancer is an aggressive tumor associated with high mortality. Optimal pain control may improve quality of life (QOL) for these patients. OBJECTIVE: To test the hypothesis that neurolytic celiac plexus block (NCPB) vs opioids alone improves pain relief, QOL, and survival in patients with unresectable pancreatic cancer. DESIGN, SETTING, AND PATIENTS: Double-blind, randomized clinical trial conducted at Mayo Clinic, Rochester, Minn. Enrolled (October 1997 and January 2001) were 100 eligible patients with unresectable pancreatic cancer experiencing pain. Patients were followed up for at least 1 year or until death. INTERVENTION: Patients were randomly assigned to receive either NCPB or systemic analgesic therapy alone with a sham injection. All patients could receive additional opioids managed by a clinician blinded to the treatment assignment. MAIN OUTCOME MEASURES: Pain intensity (0-10 numerical rating scale), QOL, opioid consumption and related adverse effects, and survival time were assessed weekly by a blinded observer. RESULTS: Mean (SD) baseline pain was 4.4 (1.7) for NCPB vs 4.1 (1.8) for opioids alone. The first week after randomization, pain intensity and QOL scores were improved (pain intensity, P< or =.01 for both groups; QOL, P<.001 for both groups), with a larger decrease in pain for the NCPB group (P =.005). From repeated measures analysis, pain was also lower for NCPB over time (P =.01). However, opioid consumption (P =.93), frequency of opioid adverse effects (all P>.10), and QOL (P =.46) were not significantly different between groups. In the first 6 weeks, fewer NCPB patients reported moderate or severe pain (pain intensity rating of > or =5/10) vs opioid-only patients (14% vs 40%, P =.005). At 1 year, 16% of NCPB patients and 6% of opioid-only patients were alive. However, survival did not differ significantly between groups (P =.26, proportional hazards regression). CONCLUSION: Although NCPB improves pain relief in patients with pancreatic cancer vs optimized systemic analgesic therapy alone, it does not affect QOL or survival.

Risk assessment of hemorrhagic complications associated with nonsteroidal antiinflammatory medications in ambulatory pain clinic patients undergoing epidural steroid injection.

UNLABELLED: We prospectively studied 1035 individuals undergoing 1214 epidural steroid injections to determine the risk of hemorrhagic complications. A history of bruising or bleeding was present in 176 (15%) patients. A platelet count was assessed in 77 patients before the epidural steroid injection; none was less than 100 x 10(9)/L. Nonsteroidal antiinflammatory drugs (NSAIDs) were reported by 383 (32%) patients, including 34 patients on multiple medications. Aspirin was the most common NSAID and was noted by 158 patients, including 104 patients on 325 mg or less per day. There were no spinal hematomas (major hemorrhagic complications). Blood was noted during needle or catheter placement in 63 (5.2%) patients (minor hemorrhagic complications). NSAIDs did not increase the frequency of minor hemorrhagic complications. However, increased age, needle gauge, needle approach, needle insertion at multiple interspaces, number of needle passes, volume of injectant, and accidental dural puncture were all significant risk factors for minor hemorrhagic complications. There were 42 patients with new neurologic symptoms or worsening of preexisting complaints that persisted more than 24 h after injection; median duration of the symptoms was 3 days (range, 1-20 days). Our results confirm those of previous studies performed in obstetric and surgical populations that document the safety of neuraxial techniques in patients receiving NSAIDs. We conclude that epidural steroid injection is safe in patients receiving aspirin-like antiplatelet medications. Minor worsening of neurologic function may occur after epidural steroid injection and must be differentiated from etiologies requiring intervention. IMPLICATIONS: Previous studies performed in obstetric and surgical populations have demonstrated that antiplatelet therapy does not increase the risk of spinal hematoma associated with spinal or epidural anesthesia and analgesia. We confirm the safety of epidural steroid injection in patients receiving aspirin-like medications.