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Laparoscopy employs highly technical equipment, and the surgeon needs special training in the technique. He should master in-depth knowledge of the use of optics, electrical principles, gas under pressure, and the physiologic changes that occur when carbon dioxide is placed in the abdominal cavity. Above all, the surgeon must adhere rigidly to guidelines for appropriate technique, and deviation will most assuredly result in complications and even death. General surgery application of laparoscopy followed a wealth of medical experience from gynecological laparoscopies, which declared the technique as safe, reduced hospital stay with little pain and disfigurement. Laparoscopic cholecystectomy started to enjoy ever increasing popularity. It retained the advantages of shorter hospital stay, more rapid return to normal activities, less pain, small incisions and less postoperative ileus compared with the traditional open cholecystectomy. Soon many procedures were done using this new technique in adults and children. Anesthesia for laparoscopy has been established with a broad usage of agents and techniques. General anesthesia using balanced anesthesia technique including intravenous induction agents like: thiopentone, propofol, etomidate, and inhalational agents like nitrous oxide, isoflurane, desflurane, has been reported. Variety of muscle relaxants including succinylcholine, mivacurium, atracurium, vecuronium aiming at rapid recovery and cardiovascular stability. Total intravenous anesthesia using agnets like propofol, midazolam and ketamine, alfentanil and vecuronium has been reported also for outpatient laparoscopy. Epidural anesthesia was considered as safe alternative to general anesthesia for outpatient laparoscopy without associated respiratory depression. As for pain relief, many methods have been used. The pain mechanism is variable and analgesia requirement is less than those of open surgery. Cited complications include pneumothorax, cardiovascular collapse, surgical emphysema and pneumo-peritoneum complications. Among the implication for anesthesia care, the importance of preoperative monitoring, careful positioning and observation during the insufflation of carbon dioxide. The drive to have short term admission to hospital would make it imperative to use short acting rapidly eliminated anesthetic drugs, avoidance of vomiting and pain by proper use of modern anti-emetics and NSAID to help in avoidance of narcotics or reduction of the requirement.
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PMID:Anesthesia for laparoscopic general surgery. A special review. 1006 70

We report a case of ruptured splenic artery aneurysm during labor in which the clinical signs were masked by epidural analgesia. A high index of clinical suspicion must be maintained in cases of atypical epidural breakthrough pain, and attending clinicians must be prepared for the unexpected when faced with a maternal collapse.
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PMID:Management of splenic artery aneurysm rupture during trial of scar with epidural analgesia. 1020 79

Regional anesthesia has become a routine part of the practice of anesthesiology in infants and children. Local anesthetic toxicity is extremely rare in infants and children; however, seizures, dysrhythmias, cardiovascular collapse, and transient neuropathic symptoms have been reported. Infants and children may be at increased risk from local anesthetics compared with adults. Larger volumes of local anesthetics are used for epidural anesthesia in infants and children than in adults. Metabolism and elimination of local anesthetics can be delayed in neonates, who also have decreased plasma concentrations of alpha(1)-acid glycoprotein, leading to increased concentrations of unbound bupivacaine. Most regional anesthetic procedures in infants and children are performed with the patient heavily sedated or anesthetized; because of this, and because a test dose is not a particularly sensitive marker of intravenous injection in the anesthetized patient, detection of intravascular local anesthetic injection is extremely difficult. The same local anesthetics used in adult anesthetic practice are also used in infants and children. Because of its extremely short duration of action, chloroprocaine has been used primarily for continuous epidural techniques in infants and children. The use of tetracaine has generally been limited to spinal and topical anesthesia. Lidocaine (lignocaine) has been used extensively in infants and children for topical, regional, plexus, epidural and spinal anesthesia. The association between prilocaine and methemoglobinemia has generally restricted prilocaine use in infants and children to the eutectic mixture of local anesthetics (EMLA). Because of its greater degree of motor block compared with other long-acting local anesthetics, etidocaine has generally been limited to plexus blocks in infants and children. Mepivacaine has been used for both plexus and epidural anesthesia in infants and children. Because postoperative analgesia is often the primary justification for regional anesthesia in infants and children, bupivacaine, a long-acting local anesthetic, is the most commonly reported local anesthetic for pediatric regional anesthesia. Given the lower toxic threshold of bupivacaine compared with other local anesthetics, the risk-benefit ratio of bupivacaine may be greater than that of other local anesthetics. Two new enantiomerically pure local anesthetics, ropivacaine and levobupivacaine, offer clinical profiles comparable to that of bupivacaine but without its lower toxic threshold. The extreme rarity of major toxicity from local anesthetics suggests that widespread replacement of bupivacaine with ropivacaine or levobupivacaine is probably not necessary. However, there are clinical situations, including prolonged local anesthetic infusions, use in neonates, impaired hepatic metabolic function, and anesthetic techniques requiring a large mass of local anesthetic, where replacement of bupivacaine with ropivacaine, levobupivacaine or (for continuous techniques) chloroprocaine appears prudent.
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PMID:Benefit and risks of local anesthetics in infants and children. 1226 41

The surgical requirement for thoracoscopy is a good view of the contents of the thorax. This is achieved by capitalizing on natural consequences and the skills of anaesthesiologists to produce a pneumothorax and collapse the ipsilateral lung--a process that is commonly enhanced by insufflating carbon dioxide. Insufflating CO2 to actively promote lung collapse creates the dynamics of a tension pneumothorax. Complications are clinically insignificant if CO2 is used judiciously. There is a body of experience using ordinary endotracheal tubes and two-lung ventilation. Techniques of one-lung ventilation are more widely reported. All the factors known to contribute to the significant increase in shunt fraction associated with one-lung ventilation apply. The manoeuvre of collapsing a lung is no longer regarded as benign. Chemical attempts to produce a reversible post-pneumonectomy pulmonary circulation have not been shown to be an improvement. Post-operative pain can be severe. The mechanism is not defined but it differs from that associated with thoracotomy. Epidural analgesia and opioids may be required. Chronic pain syndromes have been described as complications.
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PMID:Anaesthesia for thoracoscopic surgery. 1249 43

Adult obese patients with suspected or sleep test confirmed OSA present a formidable challenge throughout the perioperative period. Life-threatening problems can arise with respect to tracheal intubation, tracheal extubation, and providing satisfactory postoperative analgesia. Tracheal intubation and extubation decisions in obese patients with either a presumptive and/or sleep study diagnosis of OSA must be made within the context that there may be excess pharyngeal tissue that cannot be visualized by routine examination, and the literature indicates an increased risk of intubation difficulty. Regional anesthesia for postoperative pain control is desirable (although such management is not necessary or possible for many of these patients). If opioids are used for the extubated postoperative patient, then one must keep in mind an increased risk of pharyngeal collapse and consider the need for continuous visual and electronic monitoring. The exact management of each sleep apnea patient with regard to intubation, extubation, and pain control requires judgment and is a function of many anesthesia, medical, and surgical considerations.
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PMID:Obstructive sleep apnea in the adult obese patient: implications for airway management. 1251 63

Rescuing patients after structural collapse can be alien to emergency nurses but their ability to adapt should stand them well to provide good patient care in these unusual circumstances. Generally, they are held back until patients are released from the collapsed structures or specific requests for analgesia, anaesthesia or aggressive fluid resuscitation are made.
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PMID:When the roof caves in. 1453 94

A prospective study of 31 percutaneous vertebroplasty procedures (PVP) in 22 patients treated during January 2000 to December 2001 is presented. PVP was performed using polymethylmethacrylate (PMMA) to treat vertebral collapse due to osteoporosis and vertebral metastasis, to obtain analgesia and spinal stabilization. We analyze the efficacy and complications related to the procedure. PVP is a safe, effective and a daycare surgery. It can be performed under local anesthesia and has minimal and manageable complications.
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PMID:Percutaneous vertebroplasty: an experience of 31 procedures. 1474 29

Vertebroplasty and kyphoplasty are relatively new techniques used to treat painful vertebral compression fractures (VCFs). Vertebroplasty is the injection of bone cement, generally polymethyl methacrylate (PMMA), into a vertebral body (VB). Kyphoplasty is the placement of balloons (called "tamps") into the VB, followed by an inflation/deflation sequence to create a cavity prior to the cement injection. These procedures are most often performed in a percutaneous fashion on an outpatient (or short stay) basis. The mechanism of action is unknown, but it is postulated that stabilization of the fracture leads to analgesia. The procedures are indicated for painful VCFs due to osteoporosis or malignancy, and for painful hemangiomas. These procedures may be efficacious in treating painful vertebral metastasis and traumatic VCFs. Much evidence favors the use of these procedures for pain associated with the aforementioned disorders. The risks associated with the procedures are low but serious complications can occur. These risks include spinal cord compression, nerve root compression, venous embolism, and pulmonary embolism including cardiovascular collapse. The risk/benefit ratio appears to be favorable in carefully selected patients. The technical aspects of the procedures are presented in detail along with guidelines for patient selection. A comprehensive review of the evidence for the procedures and the reported complications is presented.
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PMID:Vertebroplasty and kyphoplasty: a comprehensive review. 1577 89

Degenerative neuromuscular diseases are characterized by a gradual decline of motor function leading to respiratory collapse, while the patients retain consciousness and cognition. The ethical challenges of caring for such patients result from the need to implement various combinations of initiating, withholding, and withdrawing life-sustaining interventions. In caring for this population of patients physicians should adhere to the ethical principles of autonomy, beneficence, nonmaleficence, and justice. A central goal of care is to avoid a decisional impasse by anticipating end-of-life issues in discussion with patients and families. The evolution of these diseases is usually slow enough to allow ample patient education, and thus physicians should foster early and frank discussions and encourage the patient to set up advance directives, designate a durable power of attorney for health care, and plan end-of-life care. Competent patients have the right to accept or refuse life-sustaining therapies, and such requests should be honored. In delivering palliative care, adequate sedation and analgesia must be provided when needed. If a decision to withhold or withdraw life support is made, patient comfort and dignity are the ultimate objectives.
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PMID:Ethical issues in the long-term management of progressive degenerative neuromuscular diseases. 1608 23

Vertebroplasty and kyphoplasty are relatively new techniques used to treat painful vertebral compression fractures (VCFs). Vertebroplasty is the injection of a vertebral body with bone cement, generally polymethylmethacrylate (PMMA). Kyphoplasty is the placement of balloons (called "tamps") into the vertebral body with an inflation/deflation sequence to create a cavity prior to the cement injection. These procedures are most often performed in a percutaneous fashion on an outpatient (or short stay) basis. The mechanism of action is unknown, but is postulated that stabilization of the fracture leads to analgesia. The procedure is indicated for painful vertebral compression fractures due to osteoporosis or malignancy, and painful hemangiomas. The procedure may have efficacy in painful vertebral metastasis and traumatic compression fractures. Much evidence favors the use of this procedure for pain associated with these disorders. The risks of the procedure are low but serious complications occur. The risks include spinal cord compression, nerve root compression, venous embolism, and pulmonary embolism including cardiovascular collapse. The risk/benefit ratio appears favorable in carefully selected patients. The technical aspects of the procedures in presented in detail along with patient selection. A comprehensive review of the evidence for the procedure and its reported complications is presented.
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PMID:Vertebroplasty and kyphoplasty. 1688 Aug 81


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