Showing papers on "Pain medicine published in 1989"

Failed intubation in the parturient.

Abstract: The a~icle by Davies e t a l . 1 attempts to outline a management plan for one of the most critical events in obstetrics, that of a failed intubation during general anaesthesia for delivery. In the authors' historical review, which was based on data from England, Scotland and Wales, the incidence of failed intubation in this circumstance is extremely low. It is unfortunate that the North American experience is not readily available. This limitation may reflect the difficulty in obtaining accurate morbidity and mortality data at the present time. Previous studies from other countries support a low frequency of difficulty. Tiret e t a l . 2 carried out a prospective review of complications associated with anaesthesia in France from 1978-1982. They examined a sample from 198,103 anaesthetics performed in 460 public hospitals. Unfortunately, complications related to an occurrence during obstetrics were not specified, but they indicated that a complication during intubation was a factor in 14 cases resulting in one comatose patient but no deaths. From Australia, the 1986 report of the Victorian Consultative Council on Anaesthetic Mortality and Morbidity ~ contains a review of 69 cases. There were four cases of failed intubation, two of which occurred during caesarean section for patients with pre-eclampsia. These patients were subsequently intubated following a plan of action, thus averting morbidity. In Canada, the CMPA a has reviewed all closed claims since 1980 which deal with failed intubation in obstetrics. Of seven cases, three resulted in death, one had severe brain damage after blind nasal intubation and one recovered after aspiration. Of the two remaining patients, one was successfully intubated by a second anaesthetist and the other survived following an emergency tracheotomy. Only three cases involved legal action. When one considers the experience of the anaesthetist and the management of failed intubation it is important to examine Lyons' paper, s Of the eight cases of difficult intubation in 2,331 general anaesthetics, seven were converted to epidural anaesthesia and one delivered vaginally after general anaesthesia was abandoned. Two

Experiences with the use of pain diaries in the care of outpatients suffering from chronic pain.

Abstract: For the present investigation 31 out-patients suffering from chronic pain received a pain diary, that is a booklet in which they recorded their pain level on visual analogue scales and daily activities several times during a day. We used weekly interviews and the patient's records in the diary to evaluate the patient's compliance and the influence of a pain diary on the pain perception and on the physician-patient-interaction. We found that most of the patients were willing and able to use the pain diary. 30 out of 31 patients kept the diary voluntarily for an average period of 4 weeks. 70% of the patients regarded the pain diary as helpful irrespective of whether or not they considered it at the same time as burden. Only 10% reported difficulties in using the pain diary. The majority of patients (70%) noticed no change by the use of the diary in their general pain perception, about 17% reported to feel an increasing fixation on their pain, while 13% felt more distance from their pain by using a pain diary. The use of a pain diary produces a survey over the pain for a longer period than a usual consultation could present. In particular the relationship between the pain level and other recorded events and activities becomes visible. The apin data become especially clear when displayed graphically in a "pain curve". In this way therapeutic interventions can be checked whether or not they are efficient. Each patient was asked at every meeting to indicate on a separate visual analogue scale the pain level he would consider bearable. This mark was accepted by all patients as their aim for the therapy, a more realistic aim than the expectation of a complete freedom from pain. When observed over a period of at least two weeks we found this mark staying constant with half of the patients. In 23.8% the patients decreased this subjectively bearable pain level more than 1 cm, in 14.3% the level was increased. In 9.5% it varied without any clear tendency. For many patients the pain diary was an impulse for an argument with their pain and life situation. Patients from this study reported a better control over their pain and improved conciousness of their own body. As the patient plays an active part the pain diary promotes an equal cooperation between physician and patient. The new information derived from a pain diary enables both patient and physician to alter their point of view.

Contamination of syringes.

Abstract: metoclopramide on plasma cholinesterase activity. Can J Anaesth 1988; 35: 476-8. 2 Kao Y J, Turner DR. Prolongation of succinylcholine block by metoclopramide. Anesthesiology 1989; 70: 905-8. 3 ZapfPW, Coghlan CHM. A kinetic method for the estimation of pseudocholinesterase using naphthyl acetate substxate. Clin Chim Acta 1974, 43: 237-42. 4 Kalow W, Genest K. A method for the detection of atypical forms of human serum eholinesterase. Determination of dibucaine numbers. Can J Biochem Physiol 1957, 35: 339-46.

Anesthesia for a patient with Williams syndrome

Abstract: A 7-year-old boy weighing 17.2 kg was scheduled for bilateral orchiopexy for repair of retentio testis. Since the age of 5, he had been pointed out to have supravalvular aortic stenosis and was diagnosed as Williams syndrome. The systolic pressure gradient between aorta and left ventricle was 20 mmHg. He had strabismus, epicanthal folds, long philtrum, thick lips, mandibular hypoplasia, and mental retardation with a developmental quotient of 3 years. A grade 2/6 systolic ejection murmur was observed at the area of aortic valve. The size of heart was normal on chest x-ray, but the ECG showed left ventricular hypertrophy. He was premedicated with atropine 0.17 mg. Anesthesia was induced with 85 mg thiopental. After the administration of 12 mg of d-tubocurarine, endotracheal intubation was performed. Anesthesia was maintained with 66% nitrous oxide in oxygen, intermittent d-tubocurarine, and caudal anesthesia with 0.25% bupivacaine 10 ml and morphine' 0.5 mg. The blood pressure in both arms was measured simultaneously with

Anaesthetic technique and pain in the newborn.

Abstract: This paper reviews the approach to pain during surgery in the newborn under five general headings: (1) current attitudes to pain in the newborn during anaesthesia and intensive care; (2) current evidence on the response of the newborn to pain; (3) current approaches to the management of pain in the newborn; (4) the complications of these approaches; (5) the resultant principles of the management of anaesthesia in the newborn.

More on acute renal failure in the Intensive Care Unit

Abstract: We read with interest the article by Corwin and Bonventre [1] about acute renal failure (ARF) in Intensive care Unit patients, particularly appreciating the section on prevention and diagnostic methods. As intensivists who care for patients with ARF we feel that more space should have been dedicated to other techniques of renal support such as continuous arteriovenous hemoflltration (CAVH), continuous arteriovenous hemodialysis (CAVHD) and continuous arteriovenous hemodialysis with sequential plasmapheresis (CAVHP/D) [2]. In these patients, as Corwin and Bouventre stated, conventional hemodialysis is often not feasible because of hemodynamic instability and also it needs facilities and trained personnel which are not always available on a 24 hour basis in many intensive care units. In 1986 we started to use the above mentioned techniques in oliguric, septic patients with multiple organ failure (MOF). In our experience CAVH, performed with a polyamide filter (FH55-FH66 Gambro, Sweden), was useful in the treatment of overhydrated or mildly hypercatabolic patients, where conventional therapy (diuretics, fluid restriction) did not achieve fluid balance. When used in highly hypercatabolic septic patients, CAVH could not prevent rises in blood urea and creatinine, and there was a high mortality rate [3]. Thereafter we began using CAVHD with the aim of obtaining satisfactory removal of the waste products of catabolism associated with good hemodynamic stability [4]. This technique causes mixed (convective and diffusive) removal of solutes by infusing a peritoneal dialysis fluid through the filter's chamber. The CAVH filters, have a relatively low cut-off in another group of patients we have added sequential plasmaphersis [2], in order to remove high molecular weight mediators involved in the process of MOF generation. We have obtained satisfactory control of sepsis and a statistically significant improvement in survival in our clinical trial, currently in progress. In our experience extracorporeal support techniques are part of the multifaceted treatment (which comprises mechanical ventilation, inotropes, nutrition and antibiotics) of a complex and multifaceted disease sepsis induced MOF. More experience is needed to further define the role of these techniques and to adapt each of them to the individual patient.