Anesthesia and analgesia
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Anesthesia and analgesia · Feb 2002
An evaluation of the cutaneous distribution after obturator nerve block.
In 1973, Winnie et al. introduced the inguinal paravascular three-in-one block, which allegedly provides anesthesia of three nerves--the femoral, lateral cutaneous femoral, and obturator nerves--with a single injection. This concept was undisputed until the success of the obturator nerve block was reassessed by using evidence of adductor weakness rather than cutaneous sensory blockade, the latter being variable in its distribution and often absent. We performed this study, therefore, to evaluate the area of sensory loss produced by direct injection of local anesthetic around the obturator nerve. A selective obturator nerve block with 7 mL of 0.75% ropivacaine was performed in 30 patients scheduled for knee surgery. Sensory deficit and adductor strength were evaluated for 30 min by using sensory tests (cold and light-touch perception) and the pressure generated by the patient's squeezing a blood pressure cuff placed between the knees. Subsequently, a three-in-one block was performed, and the sensory deficit was reassessed. The obturator nerve block was successful in 100% of cases. The strength of adductors decreased by 77% +/- 17% (mean +/- SD). In 17 patients (57%), there was no cutaneous contribution of the obturator nerve. The remaining 7 patients (23%) had an area of hypoesthesia (cold sensation was blunt but still present) on the superior part of the popliteal fossa, and the other 6 (20%) had sensory deficit located at the medial aspect of the thigh. The three-in-one block resulted in blockade of the lateral aspect of the thigh in 87% of cases, whereas the anteromedial aspect was always anesthetized. By use of magnetic resonance imaging in eight volunteers, we demonstrated that the obturator nerve has already divided into its two branches at the site of local anesthetic injection. However, the injection of blue dye after having simulated the technique in five cadavers showed that the fluid regularly spread to both branches. We conclude that after three-in-one block, a femoral nerve block may have been assessed as an obturator nerve block in 100% of cases when testing the cutaneous distribution of the obturator nerve on the medial aspect of the thigh. ⋯ Previous studies reporting an incidence of obturator nerve block after three-in-one block may have mistaken a femoral nerve block for an obturator nerve block in 100% of cases when the cutaneous distribution of the obturator nerve was assessed on the medial aspect of the thigh. The only way to effectively evaluate obturator nerve function is to assess adductor strength.
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Anesthesia and analgesia · Feb 2002
The effects of the simulated Valsalva maneuver, liver compression, and/or Trendelenburg position on the cross-sectional area of the internal jugular vein in infants and young children.
We calculated the effects of the simulated Valsalva (V), liver (L) compression, and Trendelenburg (T) position on the cross-sectional area (CSA) of the right internal jugular vein by using planimetry (Aloka ultrasound machine) in 84 infants and young children. Eight combinations of positions and interventions were studied for each patient, with the patient supine, in the T position, during the simulated V maneuver, with L compression and a combination of maneuvers. Data were analyzed by using Friedman's chi(2) test and Wilcoxon's signed rank test. An increase of >25% in the CSA of the internal jugular vein was considered significant. In infants, the maximal mean increase achieved with the combination of all 3 maneuvers was only 17.4% +/- 16.1%. As a single maneuver, the simulated V was the most effective (11.6% +/- 11.5%). In children, the combination of all 3 maneuvers performed simultaneously produced a mean 65.9% (SD +/- 44.7%) increase in the CSA, which was larger than the increase by all other maneuvers alone or in a single combination (Friedman's test, P < 0.001 and Wilcoxon's test, P < 0.002). As a single maneuver, V produced the most increase (40.4% +/- 32.2%) compared with L compression (14.3% +/- 18.9%) or T position (24.3% +/- 27.1%). ⋯ The combinations of simulated Valsalva, liver compression, and Trendelenburg maneuvers produce the maximal mean increase in the size of the internal jugular vein in infants and young children, with the Valsalva maneuver being the most effective single maneuver. This increase is significant in young children, but negligible in infants.
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Anesthesia and analgesia · Feb 2002
Sodium nitroprusside decreases leukocyte adhesion and emigration after hemorrhagic shock.
The adhesion of polymorphonuclear leukocytes to the capillary endothelium is one of the key events in the pathophysiology of hemorrhagic shock. We studied sodium nitroprusside (SNP) for its ability to modulate leukocyte-endothelial cell interactions induced by hemorrhagic shock and reinfusion of blood by using intravital microscopy of the rat mesentery. Administration of SNP at a dose of 0.1 microg x kg(-1) x min(-1) infusion neither significantly decreased mean arterial blood pressure nor significantly altered bleedout volumes in hemorrhagic rats, indicating that SNP at this dose did not modify the severity of the shock protocol. Resuscitation from 1 h of hemorrhagic shock (mean arterial blood pressure approximately 45 mm Hg) significantly increased the number of adherent and emigrated leukocytes in the rat mesenteric microcirculation. However, infusion of SNP, started 15 min before hemorrhage, and continued over the entire experimental period, markedly reduced the leukocyte adhesion after reinfusion and emigration during hemorrhagic shock and after reinfusion. We concluded that the nitric oxide donor SNP is effective at reducing the leukocyte-endothelial interaction after blood reinfusion after hemorrhagic shock in rats. ⋯ The i.v. infusion of 0.1 microg x kg(-1) x min(-1) of sodium nitroprusside, a dose that does not exert a significant vasodilator effect, reduces leukocyte adhesion and emigration after hemorrhagic shock.