ANESTHESIA ANALGESIA Journal of the International Anesthesia Research Society Editorial ‘Anemia, Hemodilution, and O, Delivery Cardiovascular Anesthesia Hemodilution, Left Ventricular Segmental Wall Motion, and Aortic Surgery Hemodilution, Isoflurane, and Oxygenation Atracurium During Hypothermic CPB Volatile Anesthetics and Regional Left Ventricular Function Halothane, Quinidine, and Cardiac Conduction Renal Function and CPB Critical Care and Trauma teLactate and Acid-Base Status Ambulatory Anesthesia Propofol, 8,0, Epilepsy, and Conscious Sedation ‘Neurosurgical Anesthesia \VAE When Prone and the Abdomen Hangs Freely ‘Transpulmonary Passage of Air Isoflurane, N,O, and CSF Pressure Partial Neuromuscular Blockade and Electromyography Obstetric Anesthesia Intrathecal Opioid for Labor Analgesia Epidural PCA: Concurrent Bupivacaine and Hydeomorphone infusion ‘Therapy for Epidural Morphine Sie Etects Adverse Esfects of 0.03% Bupivacaine Postoperatively reoxygenation, Pregnancy, and Postion Metoclopramide-Enhanced Analgesia Original Articles Detection of Myocardial Depression Lang Traction and Prostacyclin Treatment of Cholinergic Bronchospasm Bronchial Cu Inflation and the Univent Tube ‘Tracheal Intubation Without Muscle Relaxants Anesthetic Requirement for Laryngeal Mask Airway ‘otal Intravenous Anesthesia: Opioid vs Hypnotic Esmolol ECT Dose-Response Free Polymeried Hemoglobin in Hypovolemic Soock ISSN 0003-2999 Volume 75, Number 5, November 1992Sones cm ig St Sosy DB teen e's Seeder ct a oe Se derma erate a oe fio eed ie Besant elegant Sibetheiameteahcoms stant Brena cape rimaen nce (air ngitnncnaayy ne Sea cee Bye acs Sgoi cums Sacer sputred eaten ret, iis ewe eg pcan sen Se races Recreate Rey hd te i onlay diate orate itt 2 een nen pe Sees ce end eerie Sui shuar mane amma d's SSE a rt a el satis fren cacno meses rece = eae rete eas References ‘Co A. Sanisn , Sih 0, Donel, Re GN: Pan tow Season anomie debe cena ofan er 2 Cine PSK Eek PCat B Cotter Shen RN. Ue of ferecrole tgs Compre the cuaty of ep 0 ‘enous fentanyl admamson Auth alg 1869 5 Ghar GR Kowa St Pane Coven Ml, Armsong Fentr Boogorcenintornage rons easbory om MP ‘Sa an Asa Aa na = Malignant Hyperthermia During Sevoflurane Anesthesia We read with interes the article by Ochiai and colleagues (0) describing the possible association between the admin ‘station of sevoflurane and the development of malignant hyperthermia (MH). Because ofthe important implications ‘of such findings, we believe that a eral examination of ‘their case reports is necessary. We agree that sevoflurane may be aseocated wi o. In the first case report by Ochiai et al. (1), the findings are consistent with the development of ME; but we also rote that impairment of CO, absorption by sevoflurane may also cause several ofthe findings (e,inereased heart MH, a5 we had previously reported ‘ate, end-tidal CO.) The relative contribution is ficult to dlscer. In the second case, we question more strongly the Assocation between sevoflurane administration and MH. ‘Whereas i i not certain whether the malfunction of the vaporizer suspended or overevaporated the ioflrane, the ‘exposure to sevoflarane for only 3 min is not likely to have provoked MH. It has been shown tha sevoflurane isa less potent trigger of MH than other volatile anesthetics (3). The [ate onset of ME by volatile anesthetics must be considered when establishing the etiology of MH (2). Also, lethal MEL fecurzed in this patent, who had a history of general anesthesia without a previous problem. In addition, warm Skin or muscle rigidity was not shown, and the ineffective: ness of dantrolene is worthy of notice, Muscle biopsy or 8 postmortem examination ofthe hypothalamus (8), or both, ‘would have been informative, "These cases are also of interest because of the potential anesthetic interactions that may produce undesirable ef- fects. In our institute, we have used sevoflurane frequently to induce anesthesia in children because of ie rapid onset ‘of agtion. Usually, isoflurane is then used for maintenance ‘of anesthesia, The interactions between these anesthetics land others must therefore be studied, because such com: binations may be used, owing to the rapid uptake and climination of sevoflurane Hiroshi Otsuka, Mo (Osamu Kemmotsu, mp, Ao, Fccx Deparment of Ano alii Untesty Scot of Matin NISW? Seppo 040 Jon wan 2 SRT Komen Maye ana "Kemwatu Malade Bebe caren een eaevcatte ate mae peer Eee ee eae tats the euina lg Hrs ed Se OS 4+ SoReal Pc Fat Am Sep Cannulation of Vessels Using a Spring-Loaded Device CCannulaton of blood vessels fs an important part of man- aging seriously il patients, especially neonates and infants The procedure requires very fine hand control and consi- ‘erable practice. Although it is an operation performed ‘many times, it can be a daunting experience for some (I). Intravenous cannulas are designed with an introducer needle that is slightly longer and narrower than the can- ula, Difcltes are usually encountered once the vessel hhas been punctured by the needle, and the cannula is ldvanced. The needle may bend considerably during inser tion, making manipulation dificult (2). Additionally, the needle tip may be accidentally advanced or prematurely withdrawn, resulting in failure.y Efnnulay d) "2 shaped hooks (@) intravenous canal with wigs. Figure 2. Cannula held with the device spring in tension. By experiment, { have found that spring-loading the cannula greatly eases this procedure. The spring is put tunder tension before the vessel is punctured. Once the vessel is punctured, release of the spring pushes the cannula forward in a swift, smooth motion, avoiding the problems normally encountered. ‘The device (Figure 1) is constructed using a central venous pressure line guide wire that acts as a spring. While the cannula is held in place on the needle with a finger on ‘one ofthe wings, the free ends ofthe wire are hooked oiver the near side of each wing (Figure 2). This puts forward pressure on the canna, The cannula is held with the wire lunder tension, and the vessel is pierced as usual. Once the needle is within the lumen, signaled by a “flashback” of blood (2), the resisting finger can be released, and the cannula moves forward into the blood vessel. The spring and the needle are withdrawn, leaving the cannula in stu This technique was assessed in 30 infants (02% weighing <4 kg) when cannulation by the conventional method had failed. Cannulation was suecessful in 47 (34%) of these infants on the fist attempt; only 3 (6%) required a second attempt By adopting this concept, a new generation of spring loaded cannulas, long lines, and central venous pressure lines could be constructed. Kadivali M, Srivatsa, ness Hospi! of St. Cos Bary Road Rugby CV22 SPX Eglo References 1. Hope RA, Longmore JM. Mou PAS, Warns AN. Odor hand of ‘limite and ed, One Gxond Unversity Poy 0830 2 Kestin Perper venous cannule Be} Hosp Med 8737-423 468 3. Bates Henny CD How to el perp! venous ola Be) sp nied oar Use of Transesophageal Echocardiogram for Intracardiac Thrombus Related to Postoperative Atrial Fibrillation We describe a case in which a patient developed postoper tive atrial fibrillation due to an intracardiac thrombus. The patient was a 6&yrold man with a history of ingulin-dependent diabetes mellitus and previous myoc ial infarction who underwent an emergent embolectomy of the right subclavian artery. The anesthesia vas per formed by field block using 2% plain lidocaine (200 fxg) with intravenous sedation using midazolam 3. mg and Fentanyl 100 yg. At the start of the procedure, a heparin infusion was stated ata rate of 1000 Uih. The patient had. an unremarkable intraoperative course, and the heparin Infusion was discontinued at completion. On arrival at the postanesthesia recovery room, the patient's telemetry (lead I) had converted from normal sinus. rhythm to. atrial fibrillation. Eleetrocardiogram confimed the atrial fibril tion, and no ischemic changes were noted, At this time, the patient had experienced no chest pain and was hemody= namically stable. Digitalis (1.0 mg) was administered intra venously over 4 h along with verapamil 7.5 mg) in 25-mg, doses over 2 h. Heparin therapy was restarted at 1000 Urh ater a 7500-U intravenous bolus. The patient was trans- ferred to the coronary care unit, anda transthoracic echocardiogram was obtained to determine the etiology. ‘This revealed mild hypokinesis with an ejection fraction of 40%. However, the transesophageal echocardiogram also revealed the additional presence of an intracardiac throm bus. Heparin therapy was reinstituted, and the cardiac rhythm converted to normal sinus 24 h later. "The purpose of this report was to demonstrate that an intracardie thrombus is 2 treatable cause of atrial fibila- tion in the postanesthesia recovery room and that trans. ‘esophageal echocardiography was shown to be superior to the transthoracic echocardiogram in its detection (12) Ronald DeMeo, Krishnaprasad Deepika, MD Department of Aresthsoty Unters of Mio Soho f Madicine PLO. fx 016370 Miami, FL3100 References 1. Tuc PA, MtianeyL Mabel T Kroon The alain between ‘fr utes tral btn: Chest NEILL a. ian A. 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