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Combined spinal-epidural vs. epidural anesthesia in abdominal surgery

Philippine Journal of Surgical Specialties.1999;11(2):6-13.

BACKGROUND: Combined spinal-epidural anesthesia is becoming popular especially in obstetrics and orthopedics, however few studies have been done involving abdominal operations METHODOLOGY: A randomized, blind study was conducted to compare the clinical outcome of combined spinal-epidural anesthesia (CSEA) with epidural anesthesia (EA) in abdominal surgery. CSEA was established using tetracaine 0.5 percent for the spinal component and bupivacaine 0.5 percent for the epidural component, whereas EA was established using bupivacaine 0.5 percent and fentanyl. Sixty patients were enrolled (Group CSEA, n=30; Group EA, n=30) RESULTS: The ease of doing the procedures were similar in both groups. Of the two techniques, CSEA was associated with earlier onset times (p0.05), more intense motor block (100 percent in the CSEA group achieved compete motor block compared to 10 percent in the EA group). Ephedrine use was similar in both groups. Pain scores were similar in both groups. Overall patient satisfactions were higher in the CSEA groups. The incidence of shivering was higher in the EA group (33 percent) compared to CSEA group (17 percent). Pruritus was present only in the EA group (10 percent). Nauses, vomiting, and headache were absent in both groups CONCLUSIONS: CSEA is a useful and safe technique that confers advantages over the EA technique for major abdominal surgery. CSEA has low failure rates, rapidly produces a reliable spinal blockade, provides good operating conditions, and offers high level of patient satisfaction.
Human ; Aged ; Middle Aged ; Adult ; Young Adult ; Adolescent ; ANESTHESIA ; ANESTHESIA, EPIDURAL ; ANESTHESIA, SPINAL ; OBSTETRICS, ORTHOPEDICS

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Crystalloid preloading in elective cesarean section under spinal anesthesia

Cruz Ma. Concepcion L. ; Esteban-Habana Ma. Antonia

Philippine Journal of Surgical Specialties.1999;11(2):20-25.

BACKGROUND: The prevention of maternal hypotension by traditional crystalloid preloading prior to spinal anesthesia in obstetric patients undergoing spinal anesthesia has recently been questioned by many. A review of published data with unbiased comparison comparing preloading and no preloading prior to spinal anesthesia was attempted to assess the relative benefits and side-effects in terms of incidence of maternal hypotension, dose of vasopressors given and APGAR scores at one and 5 minutes. METHODS: A medline search of published randomized controlled trials (RCT) from 1966-1997 comparing crystalloid and no crystalloid preloading prior to spinal anesthesia in patients for cesarean section was done. Search for available meta-analysis on preloading, only three met the criteria for analysis. The outcome measures were limited to three due to lack of available data for comparison. RESULTS: Using the Peto Odds Ratio, analysis of the three studies showed no significant difference in the incidence of hypotension between those who were preloaded and those who were not. But a trend towards a lower incidence of hypotension among those who were preloaded was seen. Using the weighted means difference (WMD) to analyze the dose of vasopressors given, there was no significant difference between preloading and no preloading but a trend towards a greater total dose of vasopressors was seen in those not preloaded. There was no significant difference in APGAR scores in the three studies. CONCLUSION: There is no sufficient evidence to support a change in practice to no preloading prior to spinal anesthesia for elective cesarean section based on the results of this meta-analysis. Further studies must be done to increase the validity and precision of results comparing preloading and no preloading.
Human ; Female ; ANESTHESIA, SPINAL ; CESAREAN SECTION ; OBSTETRICS ; HYPOTENSIONS

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A comparison of intubating conditions and duration of activity of cisatracurium and atracurium in Filipinos for surgery at the Philippine General Hospital: A prospective, randomized, double-blind study

Jose Geraldine Raphaela B. ; Evangelista Enrico P. ; Odi Tygran RC ; Tan-Gatue Maria Asuncion ; Villegas Francis L. ; Dela Cruz-Odi Merle F.

Philippine Journal of Surgical Specialties.1999;11(2):26-31.

BACKGROUND: Cisatracurium , an R-cis, R-cis isomer of atracurium, is a benzoquinolinium non-depolarizing muscle relaxant with intermediate duration of action that has the advantage of minimal histamine release compared to the parent compound atracurium. Similar studies have described cisatracurium to have cardiovascular stability up to 7 times the ED95 dose. However, few have been conclusive owing to concomitant use of agents that can cause potential histamine release and hemodynamic effects. This study was specifically designed to minimize these variables. The promise of the clinical advantages of the use of cisatracurium merits investigation against its parent compound atracurium in the Filipino population especially in terms of hemodynamic stability when utilized intraoperatively. The study was conducted to evaluate the onset of action, conditions for intubation, duration of neuromuscular block and side effects of cisatracurium compared to atracurium among Filipino surgical patients METHODOLOGY: A prospective, randomized, double-blind study was performed in eighty one (81) healthy patients of ASA Physical Status 1 and 2 undergoing elective surgical procedures treated with either 0.15 mg/kg cisatracurium (3 x ED 95) n=39 or 0.5 mg/kg atracurium (3 x ED 95) n=42 administered over 5 seconds intravenous bolus under adequate anesthesia, before surgical stimulation. We compared the time course of the neuromuscular block and determined whether the muscle relaxants caused cutaneous and systemic evidence of histamine release. Induction of general anesthesia commenced with the use of propofol-fentanyl in oxygen. Stabilization of the Neuromuscular junction was achieved prior to the administration of the muscle relaxants with the use of tetanic stimulation of 50 Hz; for 5 seconds followed by single twitch stimuli for 2 minutes. Neuromuscular transmission was assessed by recording the mechanical twitch response to train-of-four nerve stimulations every 10 seconds. Cutaneous manifestations, blood pressures and heart rates were recorded periodically. RESULTS: Time to 95 percent block were 77.09-155.99 seconds with cisatracurium. and 64.60 - 128.21 seconds with atracurium. The administration of either muscle relaxant resulted in complete neuromuscular block in all patients providing good to excellent intubating conditions. The time to spontaneous recovery (T4:T1 ratio 80 percent) were noted to be within the range of 63.48 - 103.48 minutes for cisatracurium whereas those treated with atracurium recovered within the range of 74.76 - 92.64 minutes and none necessitated reversal from the muscle relaxants. One patient from the cisatracurium group and two from the atracurium group were noted to have cutaneous flush. CONCLUSION: When given a dose of 3 x ED 95, except for onset, cisatracurium group did not differ significantly from the atracurium group with regard to onset, duration, intubating conditions, and hemodynamic stability.
Human ; Middle Aged ; Adult ; Young Adult ; Adolescent ; INTUBATION ; HEMODYNAMIC ; ANESTHESIA ; CISATRACURIUM ; ATRACURIUM ; HISTAMINE ; MUSCLE RELAXANTS, CENTRAL

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The effect of oral clonidine premedication on the duration of hyperbaric tetracaine spinal anesthesia

Partahusniutojo Pangkuwidjaja

Philippine Journal of Surgical Specialties.1999;11(2):32-39.

BACKGROUND: In anesthesia, clonidine has been proven to be clinically useful in producing sedation, anxiolysis, and decreasing the requirement for both general and regional anesthetics. Studies have shown that oral clonidine is able to prolong the duration of spinal anesthesia when bupivacaine or isobaric tetracaine is used. This study was conducted to determine the effects of oral clonidine premedication on the duration of hyperbaric tetracaine spinal anesthesia. METHODS: Forty-six patients for lower extremity and perineal surgery under hyperbaric tetracaine spinal anesthesia were randomly grouped into two: group I - control and group II - clonidine. The clonidine group received 150 mcg oral clonidine premedication 1 hour prior to the spinal anesthesia. Sensory level was measured using the pinprick method. The onset, maximal sensory block, duration and the hemodynamic variables were determined and compared between the two groups. RESULTS: No significant differences were noted as to onset and the maximal level of sensory blockade. The mean duration of sensory analgesia was significantly prolonged in the clonidine group (298.33 min) as compared to the control group (176.73 min). Hemodynamic variables were significantly decreased in the clonidine group. CONCLUSION: This study demonstrated that 150 mcg oral clonidine given 1 hour prior to tetracaine spinal anesthesia significantly prolonged the duration of the blockade.
Human ; ANESTHESIA, SPINAL ; HEMODYNAMICS ; CLONIDINE ; BUPIVACAINE

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Autologous normovolemic hemodilution: An acceptable alternative blood transfusion technique in a Jehovahs Witness patient for thoracotomy

Ortillo Jojie Marie F.

Philippine Journal of Surgical Specialties.1999;11(2):52-55.

A case of a Jehovah's Witness patient was presented who underwent thoracotomy and decortication of the right lung with great potential for blood loss but refused homologous blood transfusion. Acute Normovolemic Hemodilution is the only autologous transfusion technique that is acceptable to the patient satisfying the objections of a archetypal Jehovah's Witness belief regarding blood transfusion. The wide margin of safety with regards to conservation of red blood cells in ANH was seen in this case thus, providing its efficiency and acceptability.
Human ; Female ; Aged ; TRANSFUSION, BLOOD ; ANESTHESIA ; INTUBATION ; OROTRACHEAL ; THORACOTOMY

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Arnold-Chiari malformation: abnormalities, concerns and the anesthetic management

Ona Gerard Raymond C. ; Tan Eden

Philippine Journal of Surgical Specialties.1999;11(2):56-61.

A wide spectrum of pediatric diseases present challenging airway problems for the anesthesiologist. To optimize the management of the difficult airway, an understanding of the pediatric airway anatomy, its peculiarities in certain diseases and the syndromes which compromise the airway is imperative. Many cases of the difficult airway are easily recognizable, while others are obscure and turn obvious only during anesthesia. The pediatric airway is always physiologically disadvantaged than the adult. There is increased oxygen consumption with less oxygen reserve. Gastric distention is an expected occurrence with mask ventilation, causing elevation of the diaphragm, reduction of functional residual capacity (FRC) and oxygen reserve, decreased lung compliance, interference with positive pressure ventilation, and increased risk of regurgitation and aspiration. Even general endotracheal anesthesia significantly decreases FRC in infants. Upper airway obstruction during general anesthesia is common because of increased sensitivity of certain inspiratory muscles to anesthetic agents. Failure to maintain a patent airway can readily result in morbidity and mortality.
Infant ; ANESTHESIA ; MYELOMENINGOCELE ; ANESTHESIOLOGIST ; PEDIATRICS ; OXYGEN ; ARNOLD-CHIARI MALFORMATION ; INTUBATION

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"Bluer than blue" a case of severe intraoperative "tet" spells

Delos Reyes Antonina Erlinda G. ; Ona Gerard C. ; Nuevo Florian R.

Philippine Journal of Surgical Specialties.1999;11(2):62-66.

This case report is about a four year old boy diagnosed since birth to have TOF. He had a co-existing cerebral infarct secondary to a cerebrovascular accident that occurred at age 3 years. Lately, he was manifesting signs and symptoms of increasing intracranial pressure secondary to brain abscess. The challenge posed is the frequent occurrence of hypercyanotic spells in this patient. How the anesthesiologist circumvented a severe case of intraoperative "tet" spells is hereby presented.
Human ; Male ; Child Preschool ; SURGERY ; ANESTHESIOLOGISTS ; INTRACRANIAL PRESSURE ; TETRALOGY OF FALLOT ; HEMODYNAMIC ; PEDIATRICS ; PHENYLEPHRINE

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Adjuvants to regional anaesthesia

de la Cruz-Odi Merle F.

Philippine Journal of Surgical Specialties.1999;11(2):67-74.

This discussion will focus on non-narcotic adjuvants to regional anaesthesia. Specifically, this paper will explore the use of alpha-2-adrenergic agonists (i.e. clonidine), anticholinestease (neostigmine) and a phencyclidine (ketamine) combined with local anaesthetics for regional and peripheral nerve blocks or used systematically to enhanced analgesia from local anaesthetic techniques. The spinal gaba- ergic system (i.e. midazolam) is primarily an inhibitory system. Enhancing inhibition is an exciting mechanism that is being explored at the present time, and is not discussed in this paper.
ANESTHESIA ; PAIN ; ANALGESIA ; HEMODYNAMIC ; ANESTHESIA, CONDUCTION ; CLONIDINE ; KETAMINE ; NEOSTIGMINE ; ANESTHETICS, LOCAL

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Sedation for pediatric patients outside the operating room: A review

Camagay Iluminada

Philippine Journal of Surgical Specialties.1999;11(2):75-85.

Sedation is defined as "a technique in which the use of a drug or drugs produces a state of depression of the central nervous system enabling treatment to be carried out, but during which verbal contact with the patient is maintained throughout the period of sedation to render unintended loss of consciousness unlikely. In this sedated state, it is believed that protective reflexes are intact, the airway is maintained independently and continuously, and the child can respond to physical stimulation or verbal command. In reality and in pediatric practice, it is difficult to realize the anxiolysis, analgesia, sleep and lack of movement necessary for the safe conduct of many diagnostic and therapeutic procedures. Many children are in fact anesthetized to achieve these aims. Loss of consciousness is a state of anesthesia with all its attendant risks. In the published guidelines for pediatric sedation, definitions of light sedation, deep sedation and anesthesia overlap. It follows, therefore, that in the interests of safety, the standards for care for sedation should be the same as those for the child undergoing anesthesia. In dental practice, "conscious sedation" in tandem with behavioural management techniques is the ideal. If, despite the use of these techniques, the child remains uncooperative, alternative approaches such as deep sedation or general anesthesia are to be considered. This elusive state of "conscious sedation" is attempted in other areas outside the operating theatres in the belief that respiratory distress is less likely to occur. In many instances, the anesthesiologist is called when the procedure cannot be carried out because, either sedation is inadequate / unsuccessful or a complication of deep sedation has taken place. Barbiturates, benzodiazepines, narcotics, antihistaminics, chloral hydrate, ketamine, and propofol are among the drugs that have been used to induce sedation. Unfortunately, serious cardiac and respiratory side effects, as well as excessive sedation have been associated with these drugs, even when normal doses are used. This review shall endeavor to present the risk factors, agents and techniques, areas of application, and recommendations for the safe use of sedation.
PEDIATRICS ; ANESTHESIA ; CENTRAL NERVOUS SYSTEM ; DENTISTRY ; PEDIATRIC ; CONSCIOUS SEDATION ; HEMODYNAMICS ; CHLORAL HYDRATE ; NITROUS OXIDE ; MIDAZOLAM ; PENTOBARBITAL

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Extubation and airway problems in the immediate recovery

Santos Nerissa D.

Philippine Journal of Surgical Specialties.1999;11(2):86-92.

All anesthesiologists, at some stage, have experienced problems after tracheal extubation, the frequency of which probably exceeds those relating to tracheal intubation. Whereas the anesthetic literature is replete with studies that the problems associated with tracheal intubation, it is unusual to find discussion concerning those following extubation. This review attempts to redress this imbalance.
AIRWAY EXTUBATION ; ANESTHESIA ; PULMONARY EDEMA ; ANOXIA

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