Slowly growing intracranial tumors, especially located in the supratentorial compartment, permit major volume-spacial compensation. Patient with large supratentorial tumor may not even present any specific symptoms or signs related to the elevated intracranial pressure. We experienced a patient who showed delayed emergence from general anesthesia for total knee replacement without any pharmacologic or metabolic causes. Computerized tomogram scan and magnetic resonance image revealed an unnoticed large supratentorial tumor considered as a cause of delayed emergence. After removal of intracranial tumor, the patient regained consciousness and discharged from the hospital in a relatively good health.
Anesthesia, General* ; Arthroplasty, Replacement, Knee ; Brain ; Compensation and Redress ; Consciousness ; Humans ; Intracranial Hypertension ; Supratentorial Neoplasms

BACKGROUND: Preemptive treatment with ketamine, a noncompetitive NMDA antagonist, may prevent establishment of postoperative hypersensitivity by blocking the sensory input that induces the central sensitization. The aim of this study was to determine if continuous preemptive administration of intravenous (IV) ketamine decreases postoperative pain. METHODS: Sixty healthy informed patients scheduled for elective abdominal hysterectomy were randomly divided into two groups of equal size and studied in a double-blind manner. Before surgical incision, patients were given 1 mg/kg of ketamine or equal volume of saline followed by IV infusion of 0.01 mg/kg/min, which was discontinued at peritoneal closure. IV morphine patient-controlled analgesia (PCA) was started in all patients at peritoneal closure. Visual analogue scale (VAS) pain scores and total morphine consumption were recorded at 1, 3, 6, 9, 12, 24, 36, and 48 hours postoperatively. RESULTS: VAS pain scores at rest were significantly less in the ketamine group than in the saline group at 1, 3, 24, 36, and 48 hr postoperatively. VAS at moving status were less in the ketamine group at 1, 3, 12, 24, 36, 48 hr postoperatively. Patients in the ketamine group had significantly lower morphine consumption throughout the study period, about 20-50% reduction in postoperative total morphine was observed. Only ketamine group experienced severe headache (10 cases), while there were no intergroup differences in other side effects such as pruritus, bad dream, and backache. CONCLUSION: These results suggest that preemptive continuous IV ketamine decreases postoperative pain intensity and IV morphine requirement, and its action lasts longer than the normal expected duration of action of ketamine.
Analgesia, Patient-Controlled ; Back Pain ; Central Nervous System Sensitization ; Dreams ; Headache ; Humans ; Hypersensitivity ; Hysterectomy ; Ketamine* ; Morphine ; N-Methylaspartate ; Pain, Postoperative ; Pruritus

Effects of epidural continuous infusion were compared with those of intermittent injection method in 50 primigravid parturients in active labor. After the intial bolus epidural injection of 0.25% bupivacaine 7-10ml, the parturients were divided randomly assigned to either continuous epidural infusion(INF) group or no infusion control(CONT) group. INF group received continuous epidural infusion of 0.125% bupivacaine 10ml h(-1). The parturients in both groups received intermittent top-ups of 0.25% bupivacaine 5ml with pain above 4 on visual analog scale. Epidural administration of bupivacaine was discontinued at the beginning of second stage of labor. No difference was noted between the two groups compared with respect to pain score during first stage of labor and to duration of epidural analgesia and second stage of labor. The mean pain score during second stage was lower and the general patient satisfaction was greater in INF group. The time interval between top-ups was longer in INF group than in CONT group. The total dose of bupivacaine administered during epidural analgesia was more in INF group than in CONT group. However the difference of hourly dose between two groups when the duration of epidural anagesia exeed four hours was not significant. No parturients in either group experienced severe hypotension, high level of sensory blockade or heavy motor blockade. We conclude that continuous epidural infusion seems capable of keeping parturient's hemodynamics stable during labor, and offers greater satisfaction and safety to the parturients.
Analgesia, Epidural* ; Bupivacaine ; Hemodynamics ; Hypotension ; Injections, Epidural ; Patient Satisfaction ; Visual Analog Scale

BACKGROUND: The pharmacologic interactions between propofol and adjuvant agents have increasingly been recognized as clinically important and the improved knowledge of these is being used to optimise the quality of total intravenous anesthesia. The aim of the present study was to investigate the effects of fentanyl, fentanyl-midazolam, and fentanyl-ketorolac as analgesic supplementations on the induction of propofol anesthesia with Diprifusor TCI. METHODS: Sixty ASA 1 patients undergoing elective diagnostic laparoscopy were randomly allocated to three groups equally according to injected adjuvant agents : group F, fentanyl 1 microgram/kg; group FM, fentanyl 1 microgram/kg-midazolam 0.05 mg/kg; group FK, fentanyl 1 microgram/kg-ketorolac 0.5 mg/kg IV before induction. Propofol target concentration of 4 microgram/ml was preset and unconsciousness with 3 min was considered as successful. Induction dose, time, success rate of induction, calculated and effective concentration, context sensitive decrement time when awakening concentration was 1.2 microgram/ml, vital signs and side effects were checked. RESULTS: Successful induction rate was 55% in the group F, 100% in the group FM, and 85% in the group FK (P< 0.05). Induction time and dose were significantly decreased in the group FM compared with the group F and FK. Calculated concentration, effective concentration, and context sensitive decrement time were significantly lower in the group FM than other groups. Injection pain score and postoperative pain score showed no differences between groups, but incidence of apnea was significantly increased in the group FM. CONCLUSIONS: Fentanyl-midazolam as a analgesic supplementation offered better quality of propofol induction using TCI, but showed increased incidence of apnea compared with fentanyl or fentanyl- ketorolac.
Anesthesia* ; Anesthesia, Intravenous ; Apnea ; Fentanyl* ; Humans ; Incidence ; Ketorolac ; Laparoscopy ; Pain, Postoperative ; Propofol* ; Unconsciousness ; Vital Signs