Bilateral neck exploration under hypnosedation: a new standard of care in primary hyperparathyroidism?
OBJECTIVE: The authors review their experience with initial bilateral neck exploration under local anesthesia and hypnosedation for primary hyperparathyroidism. Efficacy, safety, and cost effectiveness of this new approach are examined. BACKGROUND: Standard bilateral parathyroid exploration under general anesthesia is associated with significant risk, especially in an elderly population. Image-guided unilateral approaches, although theoretically less invasive, expose patients to the potential risk of missing multiple adenomas or asymmetric hyperplasia. Initial bilateral neck exploration under hypnosedation may maximize the strengths of both approaches while minimizing their weaknesses. METHODS: In a consecutive series of 121 initial cervicotomies for primary hyperparathyroidism performed between 1995 and 1997, 31 patients were selected on the basis of their own request to undergo a conventional bilateral neck exploration under local anesthesia and hypnosedation. Neither preoperative testing of hypnotic susceptibility nor expensive localization studies were done. A hypnotic state (immobility, subjective well-being, and increased pain thresholds) was induced within 10 minutes; restoration of a fully conscious state was obtained within several seconds. Patient comfort and quiet surgical conditions were ensured by local anesthesia of the collar incision and minimal intravenous sedation titrated throughout surgery. Both peri- and postoperative records were examined to assess the safety and efficacy of this new approach. RESULTS: No conversion to general anesthesia was needed. No complications were observed. All the patients were cured with a mean follow-up of 18 +/- 12 months. Mean operating time was <1 hour. Four glands were identified in 84% of cases, three glands in 9.7%. Adenomas were found in 26 cases; among these, 6 were ectopic. Hyperplasia, requiring subtotal parathyroidectomy and transcervical thymectomy, was found in five cases (16.1%), all of which had gone undetected by localization studies when requested by the referring physicians. Concomitant thyroid lobectomy was performed in four cases. Patient comfort and recovery and surgical conditions were evaluated on visual analog scales as excellent. Postoperative analgesic consumption was minimal. Mean length of hospital stay was 1.5 +/- 0.5 days. CONCLUSIONS: Initial bilateral neck exploration for primary hyperparathyroidism can be performed safely, efficiently, and cost-effectively under hypnosedation, which may therefore be proposed as a new standard of care. (+info)
Benzodiazepine premedication: can it improve outcome in patients undergoing breast biopsy procedures?
BACKGROUND: Women awaiting needle-guided breast biopsy procedures may experience high anxiety levels. A randomized, double-blind, placebo-controlled study was designed to evaluate the ability of midazolam and diazepam (in a lipid emulsion [Dizac]) to improve patient comfort during needle localization and breast biopsy procedures. METHODS: Ninety women received two consecutive doses of a study medication, one before the mammographic needle localization and a second before entering the operating room. Patients were assigned randomly to receive saline, 2.0 ml intravenously, at the two time points; midazolam, 1.0 mg intravenously and 2.0 mg intravenously; or diazepam emulsion, 2.0 mg intravenously and 5.0 mg intravenously, respectively. Patients assessed their anxiety levels before the needle localization, before entering the operating room, and on arrival in the operating room. Patients completed a questionnaire evaluating their perioperative experience at the time of discharge. RESULTS: Patient satisfaction during needle localization was significantly improved in both benzodiazepine treatment groups (vs. saline). The incidence of moderate-to-severe discomfort during needle localization was lower in the midazolam (20%) and diazepam emulsion (6%) groups compared with the saline group (70%) (P<0.05). The preoperative visual analogue scale anxiety scores were similar in all three groups. In the operating room, however, anxiety scores were 55% and 68% lower after midazolam (21+/-19) and diazepam emulsion (15+/-14) compared with saline (46+/-28). Finally, there was no difference in the time to achieve home-readiness or actual discharge time among the three groups. CONCLUSIONS: Premedication with midazolam or diazepam emulsion improved patients' comfort during needle localization procedures and significantly reduced intraoperative anxiety levels before breast biopsy procedures without prolonging discharge times. Use of diazepam emulsion may be an effective alternative to midazolam in this population. (+info)
Endovascular abdominal aortic aneurysm repair with percutaneous transfemoral prostheses deployment under local anaesthesia. Initial experience with a new, simple-to-use tubular and bifurcated device in the first 27 cases.
BACKGROUND: Modification of endografts are required to simplify and improve the safety of the endovascular management of abdominal aortic aneurysms (AAA). OBJECTIVES: The aim of this study is to evaluate the efficacy of a new custom-made, tubular and bifurcated device. MATERIALS AND METHODS: The graft consisted of a continuous, self-expanding, stainless steel, Z-stent structure, covered with a thin wall PTFE tube. Bifurcated grafts were constructed in vivo from three PTFE tubes with a continuous Z-stent structure. Twenty-seven high risk patients with a mean age of 74 (62-86) years and AAA, mean diameter 5.9 cm, were treated in the last 26 months. Tube grafts were deployed in 13 aortic and one iliac cases, bifurcated grafts in nine cases and aorto-uni-iliac grafts with femorofemoral bypass in four cases. Grafts were deployed percutaneously under local anaesthesia. Patients were followed with contrast CT periodically. RESULTS: All grafts were deployed. There were no open conversions or other major complications. There were nine proximal and one distal postoperative endoleak. Four sealed spontaneously, three were treated successfully with endovascular techniques and three are under surveillance. In the 7 (2-23) months follow-up, one patient died due to heart failure 3 months post-procedure. CONCLUSIONS: Local anaesthesia and percutaneous graft introduction simplify and improve the efficacy of the procedure. Continuous aortic graft support provides stability and reduces the risk of migration. PTFE is a flexible, low-profile material for use in endovascular stent-grafts. The bifurcation concept used offers a simple technique for bifurcated grafts. (+info)
Inadvertent inhalation anaesthesia during surgery under retrobulbar eye block.
I describe a case of inadvertent inhalation anaesthesia during surgery under retrobulbar anaesthesia and its management. Some of the hazards of supplementary oxygen delivery during monitored anaesthetic care and the actions taken to prevent this mishap recurring are discussed. (+info)
Peribulbar anaesthesia during keratoplasty: a prospective study of 100 cases.
AIMS: A prospective study was carried out in order to evaluate the efficacy and safety of peribulbar anaesthesia during keratoplasty and to describe surgical conditions. METHODS: Of 137 consecutive keratoplasties, 100 (73%) were performed under peribulbar anaesthesia. Patients received a mean volume of 16.5 (SD 4) ml (range 9-22 ml) of a mixture of etidocaine, bupivacaine, and hyaluronidase. Ocular compression duration was at least 20 minutes and intraocular pressure (IOP) was measured with a Tonopen after injection, compression, and before trephination. Degree of akinesia, pain scoring, complications, and surgical conditions were studied. RESULTS: Before trephination, IOP was 5.73 mm Hg below the preinjection value and was never above 21 mm Hg. Akinesia was complete in 80% of cases and 94% of patients found that surgery was painless. Two patients (2%) were very agitated during surgery. The last patient presented with an acute intraoperative suprachoroidal haemorrhage that did not result in a true expulsive haemorrhage despite an "open sky" situation. Surgical conditions were judged to be optimal by the patients in 92% of cases and by the surgeon in 98% of cases. CONCLUSION: These results demonstrate that peribulbar anaesthesia offers excellent anaesthesia and akinesia during keratoplasty and may be recommended for this type of surgery. (+info)
Topical anaesthesia of intact skin: liposome-encapsulated tetracaine vs EMLA.
In this randomized, double-blind study, we have compared the ability of 5% liposome-encapsulated tetracaine (amethocaine) (LET) vs 5% eutectic mixture of local anaesthetics (EMLA) to produce local anaesthesia of intact skin in 40 healthy volunteers. Volunteers had both preparations applied to their forearms under an occlusive dressing for 1 h. Superficial anaesthesia was measured by a total of nine 1-mm pinpricks on each arm. Deeper anaesthesia was assessed by single insertion of a sterile 22-gauge needle to a depth of 3 mm and pain was reported on a visual analogue scale (VAS). If the volunteer perceived greater than four of the 1-mm pinpricks, the 3-mm insertion was not performed. Results showed that the number of pinpricks perceived was significantly less (P < 0.01) for LET (median 1.0; range 0-9) vs EMLA (1.5; 0-9). In volunteers who had deeper anaesthesia assessed, there was no significant difference (P = 0.065) in VAS scores for LET (mean 1.5 (SD 1.4); n = 34) vs EMLA (2.4 (2.1); n = 28). Overall anaesthetic effect, as ranked by all of the subjects, was significantly better for LET compared with EMLA (P = 0.024). We have demonstrated that when applied in equal volumes, 5% LET produced better superficial local anaesthesia than EMLA. (+info)
Inhibition of inspiratory motor output by high-frequency low-pressure oscillations in the upper airway of sleeping dogs.
1. We utilized a chronically tracheostomized, unanaesthetized dog model to study the reflex effects on inspiratory motor output of low-amplitude, high-frequency pressure oscillations (HFPOs) applied to the isolated upper airway (UA) during stable non-rapid eye movement (NREM) sleep. 2. HFPOs (30 Hz and +/-2 to +/-4 cmH2O) were applied via a piston pump during eupnoea, inspiratory resistive loading and tracheal occlusion. 3. When applied to the patent UA during expiration, and especially during late expiration, HFPOs prolonged expiratory time (TE) and tonically activated the genioglossus muscle EMG. When applied to the patent UA during inspiration, HFPOs caused tonic activation of the genioglossus muscle EMG and inhibition of inspiratory motor output by either: (a) a shortening of inspiratory time (TI), as inspiration was terminated coincident with the onset of HFPOs; or (b) a prolonged TI accompanied by a decreased rate of rise of diaphragm EMG and rate of fall of tracheal pressure. These effects of HFPOs were observed during eupnoea and inspiratory resistive loading, but were maximal during tracheal occlusion where the additional inhibitory effects of lung inflation reflexes were minimized. 4. During eupnoea, topical anaesthesia of the UA abolished the HFPO-induced prolongation of TE, suggesting that the response was mediated primarily by mechanoreceptors close to the mucosal surface; whereas the TE-prolonging effects of a sustained square wave of negative pressure (range, -4.0 to -14.9 cmH2O) sufficient to close the airway were preserved following anaesthesia. 5. These results demonstrate that high-frequency, low-amplitude oscillatory pressure waves in the UA, similar to those found in snoring, produce reflex inhibition of inspiratory motor output. This reflex may help maintain UA patency by decreasing the collapsing pressure generated by the inspiratory pump muscles and transmitted to the UA. (+info)
Feasibility of endovascular repair of abdominal aortic aneurysms with local anesthesia with intravenous sedation.
PURPOSE: Local anesthesia has been shown to reduce cardiopulmonary mortality and morbidity rates in patients who undergo selected peripheral vascular procedures. The efforts to treat abdominal aortic aneurysms (AAAs) with endovascular techniques have largely been driven by the desire to reduce the mortality and morbidity rates as compared with those associated with open aneurysm repair. Early results have indicated a modest degree of success in this goal. The purpose of this study was to investigate the feasibility of endovascular repair of AAAs with local anesthesia. METHODS: During a 14-month period, 47 patients underwent endovascular repair of infrarenal AAAs with local anesthesia that was supplemented with intravenous sedation. Anesthetic monitoring was selective on the basis of comorbidities. The patient ages ranged from 48 to 93 years (average age, 74.4 +/- 9.8 years). Of the 47 patients, 55% had significant coronary artery disease, 30% had significant chronic obstructive pulmonary disease, and 13% had diabetes. The average anesthesia grade was 3.1, with 30% of the patients having an average anesthesia grade of 4. The mean aortic aneurysm diameter was 5.77 cm (range, 4.5 to 12.0 cm). All the implanted grafts were bifurcated in design. RESULTS: Endovascular repair of the infrarenal AAA was successful for all 47 patients. One patient required the conversion to general anesthesia to facilitate the repair of an injured external iliac artery via a retroperitoneal approach. The operative mortality rate was 0. No patient had a myocardial infarction or had other cardiopulmonary complications develop in the perioperative period. The average operative time was 170 minutes, and the average blood loss was 623 mL (range, 100 to 2500 mL). The fluid requirements averaged 2491 mL. Of the 47 patients, 46 (98%) tolerated oral intake and were ambulatory within 24 hours of graft implantation. The patients were discharged from the hospital an average of 2.13 days after the procedure, with 87% of the patients discharged less than 48 hours after the graft implantation. Furthermore, at least 30% of the patients could have been discharged on the first postoperative day except for study protocol requirements for computed tomographic scanning at 48 hours. CONCLUSION: This is the first reported series that describes the use of local anesthesia for the endovascular repair of infrarenal AAAs. Our preliminary results indicate that the endovascular treatment of AAAs with local anesthesia is feasible and can be performed safely in a patient population with significant comorbidities. The significant potential advantages include decreased cardiopulmonary morbidity rates, shorter hospital stays, and lower hospital costs. A definitive evaluation of the benefits of local anesthesia will necessitate a direct comparison with other anesthetic techniques. (+info)