[Modifications of blood supply of the cerebral hemispheres in animals of various age groups in asphyxia].
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Although the reverse temporalis muscle flap has been used clinically, the exact vascular connection between the superficial and deep temporal vessels has not been clearly defined. The purpose of this study was to investigate the vascular territory of the reverse temporalis muscle supplied by the superficial temporal vessels. Six cadaver heads were studied using a colored lead oxide injection through the superficial temporal artery. The specimens were examined macroscopically and radiographically. The reverse temporalis muscle flap was then applied to a clinical case presenting with traumatic anterior skull base defect communicating with the nasal cavity. The cadaver specimens demonstrated that the superficial temporal artery formed an average 1.3 ± 0.2 cm in width of dense vascular zone, which was located within 1.8 cm below the superior temporal line. The dense vascular network further perfused the anterior and posterior deep temporal arteries and the muscular branch of the middle temporal artery to supply the temporalis muscle. The mean perfused area of the temporalis muscle was 83 percent, ranging from 79 to 89 percent, in five cadaver heads. One cadaver revealed only 55 percent of perfused area in the absence of the muscular branch of the middle temporal artery. The consistent area without perfusion was located in the distal third of the posterior portion of the reverse temporalis muscle. In clinical cases, the reverse temporalis muscle flap was used successfully to obliterate the anterior skull base defect without evidence of muscle flap necrosis. The exact blood supply to the distal third of the posterior portion of the reverse temporalis muscle flap needs to be investigated further in vivo. Particular attention was paid to the inclusion of the muscular branch of the middle temporal artery in this flap to augment the blood supply to the temporalis muscle. (Plast. Reconstr. Surg. 103: 1181, 1999.)
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EDITOR: Thoracic epidural analgesia (TEA) is an effective technique in major abdominal surgery, but in daily clinical routine there is still no consensus on whether it should be used intraoperatively or only postoperatively. One benefit of intraoperative use of TEA should be lower analgesic requirements [1], but the conclusions have been inconsistent [2,3]. This double-blind randomized study was designed to compare two strategies that are often used in clinical practice: combined vs. balanced anaesthesia. We focused on the length of postoperative patient-controlled epidural analgesia (PCEA), because PCEA is an expensive form of analgesic treatment with costs proportional to duration [4]. Our aim was to determine whether intraoperative TEA could reduce the time of postoperative epidural treatment. Ethics Board approval was obtained, and all patients gave written informed consent. All patients scheduled for major abdominal surgery by laparotomy were screened. Inclusion criteria were age above 18 yr, ASA physical status I-III and knowing the German language. Exclusion criteria were contraindications to epidural analgesia or use of opioid analgesics during the past month. Patients were randomized to either intraoperative combined epidural/general anaesthesia (ICEA) or balanced anaesthesia (control, non-ICEA). Postoperatively both groups received PCEA. All patients were administered midazolam 7.5 or 3.75 mg, according to weight and age, 45 min before transfer. Crystalloids were infused at 10 mL kg−1 over 15 min. Then all patients underwent thoracic epidural catheterization using the midline approach and loss-of-resistance technique. Spinal placement was excluded by aspiration and the injection of a test dose of 2-3 mL bupivacaine 0.5%. Infusion of crystalloids was continued at 10 mL kg−1 h−1. General anaesthesia was induced in both groups with 3.0-5.0 mg kg−1 thiopental, 1.5-3.0 μg kg−1 fentanyl, 0.1-0.2 mg kg−1cis-atracurium or 1.0-1.5 mg kg−1 succinylcholine. The ICEA group received a 6-8 mL epidural bolus of sufentanil 1 μg mL−1 and ropivacaine 0.16%, 30 min pre-incision. Anaesthesia and analgesia were maintained with isoflurane in oxygen/air and continuous epidural infusion of sufentanil 1 μg mL−1 and ropivacaine 0.16% at 6 mL h−1. If necessary, additional epidural boluses of sufentanil/ropivacaine were administered or the rate of the epidural infusion was modified, to maintain a bispectral index (BIS) of 40-50 and clinical signs of sufficient anaesthesia. The control group received a combination of isoflurane in oxygen/air and fentanyl intravenously (i.v.). Shortly before the skin incision, 4-6 μg kg−1 fentanyl was injected. During surgery, fentanyl injection was repeated as necessary to achieve a BIS of 40-50 and clinical signs of sufficient anaesthesia. TEA was started with an 8 mL bolus of 1 μg mL−1 sufentanil in ropivacaine 0.16% at the closure of the abdomen. A continuous epidural infusion of the same sufentanil/ropivacaine solution was started immediately at 6 mL h−1. Postoperatively, both groups received continuous TEA (sufentanil 1 μg mL−1 and ropivacaine 0.16%), starting with 6 mL h−1. Additional patient-controlled analgesia via bolus was possible (4 mL bolus, 20 min lockout). The block was tested and documented immediately after the patients awoke. The 24 h sufentanil/ropivacaine requirement, additional analgesic demand and complications of epidural analgesia were documented twice daily thereafter by staff blinded to the patients' study assignments. Pain was evaluated every 4 h on a 0-100 numeric rating scale (NRS). A protocol algorithm was used for reducing the flow rate of epidural analgesics and for termination of postoperative PCEA. It was calculated that 46 patients would be needed in each group, to detect a 1-day reduction in PCEA treatment duration, at a power of 80% and P < 0.05. The data were analysed by χ2-test, paired two-tailed t-tests, Mann-Whitney rank sum test, Kaplan-Meier technique and log rank test. The analysis was undertaken using SPSS 12.0 (SPSS Inc., Chicago, IL, USA). We screened 229 consecutive patients, recruited 136 subjects and had 95 complete datasets available (53 controls and 42 ICEA). The two groups did not differ significantly in patient characteristics, ASA classification, pre-existing medical conditions, diagnoses or surgical procedures. There was no difference in duration of surgery (mean 4 h), end-tidal isoflurane concentration at any time, extubation time, fluid intake, fluid loss or mean arterial pressure. The desired BIS of 40-50 was maintained during anaesthesia in both groups. The control group needed a mean of 0.75 mg (2.8 μg kg−1 h−1) i.v. fentanyl during surgery, whereas the ICEA group needed a mean of 39 μg sufentanil epidurally (0.13 μg kg−1 h−1) but no fentanyl. Intraoperative epidural analgesia did not reduce the duration of postoperative pain treatment compared to balanced anaesthesia with i.v. opioid. The PCEA was stopped after 5 days on average, independent of whether TEA was started early, intraoperatively or postoperatively. The epidural analgesic consumption and supplemental analgesic requirements were identical in both groups. There were no significant differences in any of the four measures of dosage of sufentanil and ropivacaine: total (Fig. 1), basal, additional patient-initiated boluses or doctor-initiated additional boluses. Additional analgesia using another route such as oral or i.v. was necessary only in about 10% of the patients, independent of the study group. The pain intensity was comparably low in both groups. About two-thirds of the patients had no pain most of the day, regardless of whether it was the first or last day of PCEA treatment.Figure 1: Postoperative daily epidural sufentanil and ropivacaine requirement. Values are means+SD. There were no significant differences in these factors betweeen the two groups. ICEA: intraoperative combined epidural anaesthesia (intervention group); non-ICEA: control group with balanced anaesthesia.A possible explanation as to why intraoperative TEA was no better than postoperative TEA is that the control group received entirely sufficient intraoperative analgesia. Fentanyl was i.v. administered in our study at the high dosage of 2.8 μg kg−1 h−1. Our results are consistent with those of Burmeister and colleagues [5], who used 37 μg kg−1 h−1 sufentanil, thus an equianalgesic dose of 3.7 μg kg−1 h−1 fentanyl [6]. By contrast, Katz and colleagues applied only about 1.5 μg kg−1 h−1 fentanyl in the control group and found that they did not do as well as the experimental group [1]. Most other studies have not reported the opioids used in the control group. There were no severe complications from the epidural technique. Pulmonary and abdominal complications occurred, but there were no advantages for either group. There was no significant difference in ICU duration (mean 1.5 days) or total hospital stay (mean 24 days). The rate of nausea was 21% in non-ICEA patients vs. 7% in ICEA patients (P = 0.06), and the rate of vomiting was 8% vs. 2% (P = 0.28). Opioids are a risk factor for nausea and vomiting with a strong dose-response relationship [7]. It may be assumed that the equianalgesic dose ratio between the two study groups is 10 : 1 [6]. Comparing the equianalgesic doses (ICEA 39 μg vs. non-ICEA 75 μg sufentanil for the entire surgery time), the opioid dosage of the ICEA group seems to have been lower, perhaps due to effect of the local epidural anaesthetic. In conclusion, TEA did not reduce the duration of postoperative PCEA treatment, extubation time, complication rates, readmissions, ICU stay or hospitalization time. The most plausible explanation is that the control group received entirely adequate analgesia, which could not be improved by intraoperative TEA. At least on the basis of our results, there does not appear to be any reason to prefer intraoperative TEA or i.v. opioids, so long as the patient receives sufficient analgesia. Acknowledgements The authors would like to thank all their colleagues, the nursing staff, the Acute Pain Service members and Güven Braune, for their participation in conducting the study. The authors would also like to thank Michael Hanna, PhD, for editing the manuscript. This study was supported by a grant for C. Höhne from the B. Braun Foundation (Melsungen, Germany). The results of this study were presented in part at the 24th Congress of the European Society of Regional Anesthesia and Pain Therapy in Berlin, September 2005.
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Background Valsalva maneuver reduces pain by activating sinoaortic baroreceptor reflex arc. We planned this study to evaluate the role of valsalva in attenuating spinal needle-puncture pain. Methods Ninety American Society of Anesthesiologists (ASA) grade I and II enrolled patients undergoing elective surgery were randomized into 3 groups of 30 each. Group I (Control): didn't blow; group II (Distraction): patients blew into rubber tube; Group III (Valsalva): blew into sphygmomanometer tube and raise mercury column up to 30 mmHg for at least 20 seconds. During above procedures, spinal puncture was performed with 25-gauge spinal needle. Results Eighty-two patient data were analyzed. Incidence of spinal puncture pain was reduced to 10% (3 of 27) in Valsalva group as compared to 100% (28 of 28 in control group and 27 of 27 in Distraction group) observed in other two groups (P < 0.05). Severity of lumbar puncture pain as assessed by visual analog scale (0−10; where 0 is no pain and 10 is the worst imaginable pain) presented as Median (Interquartile range) were significantly reduced in the Valsalva group (0.0 [0.0] as compared to other 2 groups 2.0 [0.0] in the Distraction group and 3.0 [0.8] in Control group) (P < 0.05). Regarding time taken by CSF to fill spinal needle hub, there was no difference among the three groups (P > 0.05). None patient of all groups had post dural puncture headache (P > 0.05). Conclusions Valsalva can be performed routinely in ASA I and II patients undergoing spinal anesthesia as it is safe, painless and non-pharmacological method of pain attenuation. Keywords: Distraction; Lumbar puncture pain; Spinal anesthesia; Valsalva maneuver; Visual analog scale.
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The objective was to determine types and incidence of birth injuries of neonates born in Alzahra hospital. Prospectively during one year out of 7260 neonates born in Alzahra hospital 108 birth injuries which occurred in 102 neonate were studied regarding type clinical features management and hospital course. Birth injury was more common in male neonates and in those who had vaginal deliveries. Caput succedaneum (52.7% cases) was the most common cephalohematoma and asphyxia (17.6% cases) each were 2nd in frequency. Mortality rate was 5.9% and all of them had asphyxia except one who had rupture of liver in addition to asphyxia. Our study showed that the incidence of birth injury in this center is more than developed countries. It seems that special attention should be paid to management of labour to reduce perinatal morbidity and mortality in developing countries. (authors)
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Актуальность. Односторонняя спинальная анестезия с использованием малых доз местных анестетиков является недорогой, эффективной и быстро проводимой методикой. Особое значение при одностороннем блоке придается предотвращению гипотензии, контролю уровня и продолжительности блока, что может быть достигнуто применением малой дозы местного анестетика. Продолжается поиск эффективной и безопасной малой дозы гипербарического бупивакаина при проведении артроскопических операций на коленном суставе с возможностью быстрой и надежной выписки. Цель: оценка эффективности и безопасности односторонней спинальной анестезии малой дозой (5 мг) гипербарического бупивакаина при артроскопических операциях на коленном суставе с возможностью быстрой и надежной выписки. Материалы и методы. Тридцать пациентов, запланированных на проведение артроскопических операций на коленном суставе, были распределены на 2 группы по 15 человек. В группе 1 применялась спинальная анестезия с использованием стандартной дозы (7,5 мг) гипербарического бупивакаина, в группе 2 — односторонняя спинальная анестезия с использованием малой дозы (5 мг) гипербарического бупивакаина. Проводилось изучение характеристики блока, частоты развития побочных явлений и возможности выписки. Результаты. Увеличивалась частота получения сенсорного блока на уровне T12 в группе 2. При этом не отмечалось получение сенсорного блока на уровне Т10–T8 на оперируемой стороне, также не было обнаружено развитие двустороннего сенсорного и моторного блока в группе 2. Не было выявлено развития гипотензии и брадикардии в обеих группах. Более быстрое восстановление возможности ходьбы (145,6 ± 21,7 в сравнении с 180,3 ± 24,7 мин, p < 0,05, в группе 2 и 1 соответственно) и самостоятельного мочеиспускания (151,9 ± 23,2 в сравнении с 275,4 ± 32,5 мин, p < 0,05, в группе 2 и 1 соответственно) позволило обеспечить возможность более быстрой выписки пациентов (166,7 ± 28,1 в сравнении с 317,5 ± 33,9 мин, p < 0,05, в группе 2 и 1 соответственно). Выводы. Односторонняя спинальная анестезия с использованием малой дозы (5 мг) гипербарического бупивакаина может эффективно и безопасно использоваться при артроскопических операциях на коленном суставе и обеспечивать быструю и надежную выписку из больницы.
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Berger, Jerry J. MD; Pyles, Stephen T. MD; Saga-Rumley, Segundina A. MD Author Information
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