Successful Anesthesia Research Articles

Humanitarian Surgical Missions: Guidelines for Successful Anesthesia Support.

Many anesthesiologists and CRNAs are provided little training in preparing for a humanitarian surgical mission. Furthermore, there is very little published literature that outlines how to plan and prepare for anesthesia support of a humanitarian surgical mission. This article attempts to serve as an in-depth planning guide for anesthesia support of humanitarian surgical missions. Recommendations are provided on planning requirements that most anesthesiologists and CRNAs do not have to consider on routinely, such as key questions to be answered before agreeing to support a mission, ordering and shipping supplies and medications, travel and lodging arrangements, and coordinating translators in a host nation. Detailed considerations are included for all the phases of mission planning: advanced, mission-specific, final, mission-execution, and postmission follow-up planning, as well as a timeline in which to complete each phase. With the proper planning and execution, the anesthetic support of humanitarian surgical missions is a very manageable task that can result in an extremely satisfying sense of accomplishment and a rewarding experience. The authors suggest this article should be used as a reference document by any anesthesia professional tasked with planning and supporting a humanitarian surgical mission.

Anesthesia for cesarean section in a patient with isolated unilateral absence of a pulmonary artery

Congenital unilateral absence of a pulmonary artery (UAPA) is a rare anomaly. Although there are several reports regarding pregnancy in patients with unilateral absence of a pulmonary artery, there are no case reports describing anesthesia for Cesarean section in a patient with unilateral absence of a pulmonary artery. We present a patient with unilateral absence of a pulmonary artery who underwent Cesarean sections twice at the ages of 24 and 26 years under spinal anesthesia for surgery and epidural analgesia for postoperative pain relief. Both times, spinal anesthesia and epidural analgesia enabled successful anesthesia management without the development of either pulmonary hypertension or right heart failure. Spinal anesthesia combined with epidural analgesia is a useful anesthetic method for a Cesarean section in patients with unilateral absence of a pulmonary artery.

Ultrasound imaging increases first-attempt success rate of neuraxial block in elderly patients

Objective: To verify whether preprocedural ultrasound of the lumbar spine could improve first-attempt success rate (defined as a successful neuraxial anesthesia with only one skin puncture) of neuraxial block in elderly patients. Methods: From septemble 2015 to February 2016, 200 elderly patients undergoing lower-limb surgery with neuraxial block at the Peking Universty Third Hospital were enrolled in this study.RandA 1.0 software was used to randomize patients into two groups: conventional surface landmark-guided group (group LM) and ultrasound-assisted group (group US). Ultrasound scanning of the lumbar spine was performed to determine the suitable insertion point of US group, using a low-frequency (2-5 MHz) curved-array probe in both paramedian sagittal oblique plane and transverse median plane.Spinal anesthesia was done via the paramedian approach.The primary outcome was the rate of successful access to subarchnoid space on the first needle insertion attempt.Secondary outcomes included the following: number of needle insertion attempts, number of needle redirection times, actual epidural needle insertion depth, time taken to eastablish landmarks, time taken to perform the spinal anesthesia (the duration between local infiltration and bupivacaine injection), procedure time (the duration from sterilizing the back to converting into supine position), total time (the sum of the time to establish landmarks and the procedure time), adverse events during the procedure and anesthesia related complications. Results: A total of 191 patients successfully received combined spinal-epidural anesthesia by resident anesthesiologists, 9 patients (7 patients in group LM vs 2 patients in group US) failed.The first-attempt success rate in group LM was 37.6%, while the first-attempt success rate in group US was 68.4%, the difference between the two groups was significant (χ2=18.112, P<0.01). In group LM, the number of needle insertion attempts and needle redirection attempts were 2(1, 3) and 5(3, 10), respectively. In group US, the number of needle insertion attempts and needle redirection attempts were 1(1, 2) and 3(0, 5), respectively.The differences in the number of needle insertion attempts and needle redirection attempts between the two groups were significant (Z=-4.132, -4.077, all P<0.01). In group US, the time spent on determining the insertion point, on puncture, on finishing the procedure and the total time were as the following: 2.8(2.6, 3.1), 2.5(1.8, 4.1), 7.8(6.5, 8.9), 10.6(9.5, 11.9) min.In contrast, in group LM, those indices were as the following: 0.4(0.3, 0.4), 4.1(2.2, 6.3), 8.8(7.5, 11.4), 9.2(7.8, 11.9) min.There were significant differences in the above factors between the two groups (Z=-11.931, -4.025, -3.550, -3.290, all P<0.01). The paramedian sagittal oblique scanning image was superior to that of the transverse median plane. Conclusions: For elderly patients, ultrasound imaging before neuraxial block increases first-attempt success rate, decreases puncture time.The strengths of prepuncture ultrasound scanning outweighs its longer total time.

Effect of preoperative oral analgesics on pulpal anesthesia in patients with irreversible pulpitis-a systematic review and meta-analysis.

The objectives of this study were to assess the efficacy of preemptive oral administration of single dose of non-steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen on the local anesthetic success in adults with irreversible pulpitis and to find the possible covariates that could predict treatment effect. A systematic search using electronic databases up to March 2015 was conducted. Odds ratio (OR) and 95% confidence intervals (CIs) were estimated using random and fixed-effect inverse variance method. Subgroup and meta-regression analyses were conducted to assess the potential source of heterogeneity. Results showed that preemptive analgesics are more effective than placebo in increasing anesthetic success (OR=0.30, CI% 0.24-0.39, p=0.000) [Q=55.860 (p=0.001)]. In the subgroup analysis, administration of NSAIDs as monotherapy, ibuprofen as mono- vs. combination therapy, oxicam type drugs as monotherapy, and acetaminophen as combination therapy were significantly more effective in increasing anesthetic success OR=0.25, CI% 0.16-0.38, p=0.00, Q=40.539 (p=0.003); OR=0.44, CI% 0.26-0.75, p=0.00, Q=12.833 (p=0.011); OR=0.48, CI% 0.30-0.74, p=0.002, Q=15.898 (p=0.14); OR=0.30, CI% 0.16-0.38, p=0.001, Q=7.506 (p=0.02); OR=0.10, CI% 0.16 0.38, p=0.001, Q=5.075 (p=0.07), respectively. However, there was no significant difference in increasing anesthetic success between treatment and placebo arms when acetaminophen was administrated alone. In meta-regression analysis, an association between different types of NSAIDs (indomethacin, diclofenac potassium, and oxicam-type drugs) and articaine with treatment effect was observed. The administration of preemptive analgesics can induce superior intraoperative analgesia for patients with irreversible pulpitis. However, strategies such as co-administration of certain types of analgesics and anesthetic solution might be predictors of treatment effect. Additionally, there was no association between different timing and dosage of analgesics and treatment effect. When compared to placebo, preemptive oral analgesics are superior in achieving anesthetic success in inflamed pulp.

How to manage a difficult airway

Veterinary patients may have problematic airways as a result of anatomy or disease, and with brachycephalic breeds becoming increasingly popular pets in the UK, the registered veterinary nurse (RVN) must be confident when dealing with a difficult intubation. This article will discuss some ways to prepare for these challenging patients, which will increase the chances of a successful anaesthetic.

Surgical excision of the breast giant fibroadenoma under regional anesthesia by Pecs II and internal intercostal plane block: a case report and brief technical description: a case report.

A 22-years-old female patient at 171 cm and 67 kg visited the Department of Breast Surgery of the hospital with a mass accompanied with pain on the left side breast as chief complaints. Since physical examination revealed a suspected huge mass, breast surgeon decided to perform surgical excision and requested anesthesia to our department. Surgery of breast tumor is often under local anesthesia. However, in case of big size tumor, surgery is usually performed under general anesthesia. The patient feared general anesthesia. Unlike abdominal surgery, there is no need to control visceral pain for breast and anterior thoracic wall surgery. Therefore, we decided to perform resection under regional anesthesia. Herein, we report a successful anesthetic and pain management of the patient undergoing excision of a huge breast fibroadenoma under regional anesthesia using Pecs II and internal intercostal plane block.

The Effect of Maxillary First Molar Root Length on the Success Rate of Buccal Infiltration Anesthesia

IntroductionSeveral variables may influence anesthesia success in maxillary molars. This investigation was conducted to evaluate the effect of root length on the success rate of infiltration injections of 2% lidocaine with 1:80,000 epinephrine. MethodsOne hundred maxillary first molars with irreversible pulpitis were treated. After the administration of a buccal infiltration injection of 2% lidocaine with 1:80,000 epinephrine, the patients' pain during dentin cutting, pulp exposure, and root canal instrumentation were evaluated using the Heft-Parker visual analog scale. No or mild pain was considered as success. Data were analyzed by the point-biserial correlation test and receiver operating characteristic curve analysis. ResultsOverall, 61% of the teeth had successful anesthesia after the administration of a single buccal infiltration injection of anesthetic solution. The point-biserial correlation test showed that the teeth that had palatal and distobuccal roots with longer root lengths showed significantly higher anesthesia failure (P < .05). However, receiver operating characteristic curve analysis did not show a clinically useful cutoff point of root length corresponding with anesthesia failure. ConclusionsMaxillary first molars having irreversible pulpitis with longer roots may have more anesthesia failures after a single buccal infiltration injection with 2% lidocaine and 1:80000 epinephrine.

Effect of Sodium Bicarbonate Buccal Infiltration on the Success of Inferior Alveolar Nerve Block in Mandibular First Molars with Symptomatic Irreversible Pulpitis: A Prospective, Randomized Double-blind Study

IntroductionThe purpose of this prospective, randomized, double-blind study was to evaluate the effect of a buccal infiltration of sodium bicarbonate on the anesthetic success of the inferior alveolar nerve block (IANB) for mandibular first molars in patients with symptomatic irreversible pulpitis. MethodsOne hundred patients diagnosed with symptomatic irreversible pulpitis of a mandibular first molar were selected. The patients randomly received a buccal infiltration injection of either 0.7 mL 8.4% sodium bicarbonate with 0.3 mL 2% lidocaine containing 1:80,000 epinephrine or 0.7 mL sterile distilled water with 0.3 mL 2% lidocaine containing 1:80,000 epinephrine in a double-blind manner. After 15 minutes, all the patients received conventional IANB injection using 3.6 mL 2% lidocaine with 1:80,000 epinephrine. Access cavity preparation was initiated 15 minutes after the IANB injection. Lip numbness was a requisite for all the patients. Success was determined as no or mild pain on the basis of Heft-Parker visual analog scale recordings upon access cavity preparation or initial instrumentation. Data were analyzed using the t, chi-square and Mann-Whitney U tests. ResultsThe success rate after the buccal infiltration of sodium bicarbonate was 78%, whereas without the buccal infiltration of sodium bicarbonate it was 44% (P < .001). ConclusionsA buccal infiltration of 0.7 mL 8.4% sodium bicarbonate increased the success rate of IANBs in mandibular first molars with symptomatic irreversible pulpitis.

Anesthetic Efficacy in Irreversible Pulpitis: A Randomized Clinical Trial.

Inferior alveolar nerve block has a high failure rate in the treatment of mandibular posterior teeth with irreversible pulpitis. The aim of this study was to compare the anesthetic efficacy of 4% articaine, 2% lidocaine and 2% mepivacaine, all in combination with 1:100,000 epinephrine, in patients with irreversible pulpitis of permanent mandibular molars during a pulpectomy procedure. Sixty-six volunteers from the Emergency Center of the School of Dentistry, University of São Paulo, randomly received 3.6 mL of local anesthetic as a conventional inferior alveolar nerve block (IANB). The subjective signal of lip numbness, pulpal anesthesia and absence of pain during the pulpectomy procedure were evaluated respectively, by questioning the patient, stimulation using an electric pulp tester and a verbal analogue scale. All patients reported the subjective signal of lip numbness. Regarding pulpal anesthesia success as measured with the pulp tester, the success rate was respectively 68.2% for mepivacaine, 63.6% for articaine and 63.6% for lidocaine. Regarding patients who reported no pain or mild pain during the pulpectomy, the success rate was, respectively 72.7% for mepivacaine, 63.6% for articaine and 54.5% for lidocaine. These differences were not statistically significant. Neither of the solutions resulted in 100% anesthetic success in patients with irreversible pulpitis of mandibular molars.

Comparative Study of the Localisation of the Epidural Space Using Epidural Balloon Technique versus Saline Filled Syringe Technique – A Prospective, Randomised Study

Background and aims:The success of epidural anaesthesia begins with proper identification of epidural space. There are different techniques used for identification of the epidural space. In this study we compare the localisation of epidural space using epidural balloon technique versus normal saline filled syringe technique .Method: 200 adult patents of ASA I &II status posted for elective lower abdominal and lower limb surgery were randomly allocated in two groups of 100 each. After taking consent and IV access epidural anaesthesia was given to the patients. In group I epidural space was localised by epidural balloon technique while in group II epidural space was located by normal saline filled syringe technique using the loss of resistance method. The parameters studied were time taken for epidural space localisation, the number of attempts,the ease of passing the epidural catheter after localisation, success or failure rate of the localisation of the epidural space by resident anaesthesiologistsand the incidence of complications if any.Student unpaired ‘t’ test and chi square test were used for statistical analysis. Results:90% cases from group I(epidural balloon group) had localisation of epidural space in first attempt which was significantly more as compared to 78% in group II(saline filled syringe group). Mean duration of procedure in group I was 20.74 seconds which was significantly less as compared to 43.54 seconds in group II. 12% of cases from group II had complications during the procedure which was significantly more as compared to none from group I. Conclusion: For epidural space localisation epidural balloon technique is better than saline filled syringe technique in terms of number of attempts, mean duration of procedure, incidence of complications and ease of technique.

Comparison of the Anesthetic Efficacy of Mepivacaine and Lidocaine in Patients with Irreversible Pulpitis: A Double-blind Randomized Clinical Trial

IntroductionThe objective of this study was to compare the anesthetic efficacy of 2% mepivacaine combined with 1:100,000 epinephrine with 2% lidocaine combined with 1:100,000 epinephrine during pulpectomy of mandibular posterior teeth in patients with irreversible pulpitis. MethodsForty-two patients with irreversible pulpitis who were admitted to the Emergency Center at the University of São Paulo School of Dentistry volunteered to take part in the study and were randomized to receive conventional inferior alveolar nerve block containing 1.8 or 3.6 mL of either 2% mepivacaine with 1:100,000 epinephrine or 2% lidocaine with 1:100,000 epinephrine. We recorded patients' subjective assessments of lip anesthesia, absence/presence of pulpal anesthesia tested by using electric pulp stimulation, and absence/presence of pain during the subsequent pulpectomy by using a verbal analogue scale. ResultsAll patients tested reported lip anesthesia after application of either type of inferior alveolar nerve block. Pulpal anesthesia success rates measured by using the pulp tester were satisfactory for both solutions (86% for mepivacaine and 67% for lidocaine). Success rates according to patient report of no pain or mild pain during pulpectomy were higher for mepivacaine solution (55%) than for lidocaine solution (14%). The differences between mepivacaine and lidocaine were statistically significant. ConclusionsMepivacaine resulted in effective pain control during irreversible pulpitis treatments. The success rates with either solution were not high enough to ensure complete pulpal anesthesia.

The history of acupuncture anesthesia for pneumonectomy in Shanghai during the 1960s

The success of acupuncture anesthesia (AA) for pneumonectomy in Shanghai in 1960 was a key event for AA gaining practical clinical application. The effort was a close collaboration between the Shanghai First Tuberculosis Hospital and the Shanghai Institute of Acupuncture and Moxibustion. One of the most important factors of AA success was the great financial and political support provided by the Chinese central government and Shanghai local government. In December 1965 the State Science and Technology Commission of China issued a formal document acknowledging AA as an important first-level national achievement of the integration of Chinese and Western medicine, and a collaborative effort of the whole scientific community in China. AA was an important influential factor that helped acupuncture spread across the world.

Ultrasound-guided bilateral combined inguinal femoral and subgluteal sciatic nerve blocks for simultaneous bilateral below-knee amputations due to bilateral diabetic foot gangrene unresponsive to peripheral arterial angioplasty and bypass surgery in a coagulopathic patient on antiplatelet therapy with a history of percutaneous coronary intervention for ischemic heart disease: A case report.

Background:Patients on antiplatelet therapy following percutaneous coronary intervention can become coagulopathic due to infection. Performing regional anesthesia for bilateral surgery in such cases is challenging. We report a case of successful combined inguinal femoral and subgluteal sciatic nerve blocks (CFSNBs) for simultaneous bilateral below-knee amputations in a coagulopathic patient on antiplatelet therapy.Methods:A 70-year-old male patient presented with pain in both feet due to diabetic foot syndrome. The condition could not be managed by open amputations of the toes at the metatarsal bones and subsequent antibiotic therapy. Computed tomographic angiography showed significant stenosis in the arteries supplying the lower limbs, indicating atherosclerotic gangrene in both feet. Balloon angioplasty and bypass surgery with subsequent debridements with application of negative-pressure wound therapy and additional open amputations did not improve the patient's clinical condition: his leukocyte counts and C-reactive protein levels were above the normal range, and his prothrombin and activated partial thromboplastin times were increased.Results:Simultaneous bilateral below-knee amputations were performed under ultrasound-guided CFSNBs. Following left CFSNBs using 45 mL of a local anesthetic mixture (1:1 ratio of 1.0% mepivacaine and 0.75% ropivacaine), the left below-knee amputation was performed for 76 minutes. Subsequently, under right CFSNBs using 47 mL of the local anesthetic mixture, the right below-knee amputation proceeded for 85 minutes. Throughout each surgery, dexmedetomidine was continuously administered, and a sensory blockade was well maintained in both limbs. The patient did not complain of pain due to regression of the first CFSNBs during the second surgery. The CFSNBs successfully prevented tourniquet pain. Local anesthetic systemic toxicity (LAST) and hemodynamic instability due to tourniquet deflation and administration of dexmedetomidine did not occur. No additional analgesic was required to supplement insufficient surgical anesthesia. Postoperatively, no neurologic complications related to the CFSNBs were reported.Conclusion:The timely placement of bilateral CFSNBs immediately before the corresponding limb surgery, which lasted for less than 2 hours, provided successful surgical anesthesia in both lower limbs without LAST or pain due to regression of the CFSNBs that were performed during the first surgery.

Hemicolectomy in a patient with aortic valve disease: Case report

Patients with valve disease are at a higher risk of perioperative complications in the context of non-cardiac surgery. The active involvement of the anaesthetist from the moment of the pre-anaesthesia assessment to determine the severity of the disease is crucial.The purpose of this report on the management of a clinical case is to highlight the need for a multidisciplinary approach to the patient with heart disease.We present the case of a patient in the eighth decade of life with severe aortic stenosis, and a 46mm infra-renal abdominal aortic aneurysm; chronic obstructive pulmonary disease, controlled arterial hypertension; and a lymphoproliferative process. Following the pre-anaesthesia assessment, valve repair surgery was indicated prior to a surgical procedure for colon cancer resection. Key to the successful management of this patient was pre-operative optimization with cardiac surgery and adjustment of the pharmacological treatment, plus haemodynamic monitoring as a basis for decision-making during the perioperative period using a minimally invasive device (Vigileo®). Spinal analgesia with intrathecal morphine was combined with general anaesthesia. The patient remained stable with CI 2.3–3l/min/m2, SVV 2–7% and ScvO2 74–67%.As a result of the successful anaesthetic and surgical process, we concluded that it is our duty at the present time to know and apply the recommendations contained in the guidelines developed by the anaesthesia and cardiology societies and their regular updates, as they allow clinicians to make decisions in accordance with evidence-based protocols.

Hemicolectomía en un paciente con valvulopatía aórtica: reporte de caso

Patients with valve disease are at a higher risk of perioperative complications in the context of non-cardiac surgery. The active involvement of the anaesthetist from the moment of the pre-anaesthesia assessment to determine the severity of the disease is crucial.The purpose of this report on the management of a clinical case is to highlight the need for a multidisciplinary approach to the patient with heart disease.We present the case of a patient in the eighth decade of life with severe aortic stenosis, and a 46mm infra-renal abdominal aortic aneurysm; chronic obstructive pulmonary disease, controlled arterial hypertension; and a lymphoproliferative process. Following the pre-anaesthesia assessment, valve repair surgery was indicated prior to a surgical procedure for colon cancer resection. Key to the successful management of this patient was pre-operative optimization with cardiac surgery and adjustment of the pharmacological treatment, plus haemodynamic monitoring as a basis for decision-making during the perioperative period using a minimally invasive device (Vigileo®). Spinal analgesia with intrathecal morphine was combined with general anaesthesia. The patient remained stable with CI 2.3 - 3 l/min/m2, SVV 2 - 7% and ScvO2 74- 67%.As a result of the successful anaesthetic and surgical process, we concluded that it is our duty at the present time to know and apply the recommendations contained in the guidelines developed by the anaesthesia and cardiology societies and their regular updates, as they allow clinicians to make decisions in accordance with evidence-based protocols.

Comparative Evaluation of Mental Incisal Nerve Block, Inferior Alveolar Nerve Block, and Their Combination on the Anesthetic Success Rate in Symptomatic Mandibular Premolars: A Randomized Double-blind Clinical Trial

IntroductionThe purpose of this study was to compare the effectiveness of mental incisive nerve block (MINB) and inferior alveolar nerve block (IANB) that were given alone or in combination to provide anesthesia to symptomatic mandibular premolars. MethodsOne hundred fifty-three patients participated in this randomized, double-blind clinical trial. The patients were divided into 3 groups; first group received MINB with 2 mL 2% lidocaine with 1:200,000 epinephrine and a mock IANB with 2 mL sterile saline, patients in group 2 received mock MINB and an IANB with 2 mL 2% lidocaine, and patients in group 3 received both MINB and IANB with 2 mL each of 2% lidocaine. Access cavity preparation was initiated after 10 minutes. Success was defined as no pain or faint/weak/mild pain during endodontic access preparation and instrumentation. The anesthetic success rates were analyzed with Pearson χ2 test at 5% significance levels. ResultsThe MINB and IANB gave 53% and 47% anesthetic success rates, respectively, with no significant difference between them. Adding an IANB to MINB significantly improved the success rates to 82%. ConclusionsA combination of MINB and IANB can provide improved local anesthesia for symptomatic mandibular premolars.

Double‐dorsal versus single‐volar digital subcutaneous anaesthetic injection for finger injuries in the emergency department: A randomised controlled trial

The objective of this present study is to compare pain associated with the double-dorsal versus a single-volar subcutaneous injection in the provision of digital anaesthesia for finger injuries presenting to the ED. A randomised controlled trial from November 2012 to January 2014 at a single adult tertiary-referral hospital. ED patients with finger injuries requiring digital anaesthesia was randomised to either the double-dorsal or a single-volar subcutaneous injection technique. The primary outcome was patient reported injection pain measured on a 100 mm visual analogue scale with the assessor blinded to the injection technique. The secondary outcome was success of anaesthesia defined as ability to perform the assessment and treatment without further anaesthetic supplementation after 5 min. Eighty-six patients were enrolled. Median (IQR) age was 34 (24-47) years and 79% were men. The majority (66.3%) had distal phalanx injuries. Forty patients were randomised to the double-dorsal and 46 to a single-volar subcutaneous injection technique. The mean (standard deviation) pain score of the double-dorsal injection was 39.1 (24.2) and a single-volar injection was 37.3 (24.5) with a difference of 1.8 (95% CI -8.8 to 12.3). Digital anaesthesia was successful in 64.9% of the double-dorsal and 71.7% of the single-volar subcutaneous injections, a difference of 6.8% (95% CI -12.7 to 26.3). In ED patients with finger injuries requiring digital anaesthesia, both the double-dorsal or single-volar subcutaneous injection techniques have similar pain of injection and success rates of anaesthesia. Single-volar injection appears suitable alternative to the commonly performed double-dorsal injection in the ED.

Efficacy of Ketorolac Buccal Infiltrations and Inferior Alveolar Nerve Blocks in Patients with Irreversible Pulpitis: A Prospective, Double-blind, Randomized Clinical Trial

IntroductionThe purpose of this prospective, randomized, double-blind, placebo-controlled study was to determine whether ketorolac buccal infiltrations (BIs) helped to improve the success of inferior alveolar nerve blocks (IANBs) in patients with acute irreversible pulpitis (AIP). MethodsForty adult volunteers with AIP in a mandibular molar were included in this study. Patients were instructed to evaluate their pain by using a Heft-Parker visual analog scale. They were randomly divided into 2 groups (n = 20). All patients received standard IANB injection and after that a BI of 4% articaine with 1:100,000 epinephrine. After 5 minutes, 20 patients received a BI of 30 mg/mL ketorolac, and the other received a BI of normal saline (control group). Endodontic access cavity preparation (ACP) was initiated 15 minutes after the IANB when the patient reported lip numbness and had 2 electric pulp tests with no responses. The patient's pain during caries and dentin removal, ACP, and canal length measurements (CLM) was recorded by using Heft-Parker visual analog scale. Successful anesthesia was defined as no or mild pain during any of these steps, without the need for additional injection. Data were statistically analyzed by using Mann-Whitney U and χ2 tests. ResultsSuccessful anesthesia after an IANB plus BI of articaine was obtained in 15% of patients in the control group at the end of CLM. Adding BI of ketorolac significantly increased the success rate to 40% (P < .05). Patient's pain during ACP and CLM was significantly lower in the ketorolac group (P < .05). ConclusionsKetorolac BI can increase the success rate of anesthesia after IANB and BI with articaine in patients with AIP.

Successful Epidural Anesthesia for Cesarean Delivery in a Woman With Fontan Repair

The cohort of the adult population with congenital heart disease is steadily growing, as surgical and medical management advances; and many women with congenital heart disease are becoming pregnant and presenting to the labor and delivery suite [1]. The anesthesiologist must therefore have an understanding of the physiology of the corrected heart lesion and the impact of the physiologic changes of pregnancy [2]. A woman status post-Fontan procedure requiring cesarean delivery is presented.

Optimum dose of bupivacaine for spinal anesthesia with epidural volume extension in patients undergoing cesarean delivery

Objective To determine the optimum dose of bupivacaine for spinal anesthesia with epidural volume extension (EVE) in patients undergoing cesarean delivery. Methods A total of 100 parturients, weighing 55-100 kg, with body height of 155-170 cm, of American Society of Anesthesiologists physical status Ⅰ or Ⅱ, scheduled for elective cesarean delivery, were included and randomized to receive bupivacaine at 5 different doses (A, B, C, D, and E groups) using a random number table, with 20 patients in each group.In A, B, C, D, and E groups, bupivacaine 6.75, 7.50, 8.25, 9.00 and 9.75 mg were injected into the subarachnoid space, respectively, and the volume was all 1.5 ml.After successful spinal anesthesia, an epidural catheter was placed, and normal saline 10 ml was given through the catheter to perform EVE.A successful spinal block was defined as attainment of sensory block of at least T5 within 15 min after EVE along without requirement for additional local anesthetics within 60 min after EVE.The rate of successful spinal anesthesia, time to reach sensory block of T5, the maximum level of sensory block, and the first requirement for local anesthetics were recorded.The occurrence of hypotension, tachycardia, bradycardia, nausea, vomiting, chest distress, dyspnea, shivering, and referred pain and consumption of metaraminol were recorded during spinal anesthesia.Apgar scores at 1 and 5 min after birth were recorded. Results With the increasing doses of bupivacaine, the efficacy of spinal anesthesia was enhanced, and the occurrence of adverse reactions was increased.Compared with group C, the rate of successful spinal anesthesia, and the maximum level of sensory block were significantly increased, the time to reach sensory block of T5 was shortened, and the incidence of hypotension and nausea and consumption of metaraminol were increased in group E; the time to reach sensory block of T5 was significantly shortened, Apgar scores at 1 min after birth were increased (P 0.05). Compared with group D, the time to reach sensory block of T5 was significantly shortened, the incidence of nausea and consumption of metaraminol were increased (P 0.05). Conclusion The optimum dose of bupivacaine for spinal anesthesia with EVE is 9.00 mg in patients undergoing caesarean delivery. Key words: Dose-response relationship, drugs; Cesarean section; Bupivacaine; Anesthesia, spinal