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Densities of cerebrospinal fluid and spinal anaesthetic solutions in surgical patients at body temperaturePurpose: To determine the densities of cerebrospinal fluid (CSF) in patients for surgery under spinal anaesthesia. The densities of the CSF were compared with the densities of local anaesthestic solutions and their mixtures with commonly used spinal opioids. Method: One ml of CSF was collected from 131 consecutive patients that consented to the study at the time of spinal anaesthesia. Densities were measured at 37~ in a Density Meter that displayed density to the fourth decimal point and was accurate to 0.00003 g-ml -l. The densities of a selection of spinal anaesthetic drugs were also measured, Results: The mean CSF density in the study population was 1.00059 ___ 5D 0.00020. In men of all ages, the mean CSF density was I .00067 ---0.00018 g'ml-l; in postmenopausal women I .00060 -0.00015 g-ml-l; in premenopausal non-pregnant women I .00047 +-0.00076 g'ml-l; and in pregnant women 1.00033 ___ 0.00010 g.ml -I . There were differences between the CSF densities in pregnant women compared with men (P = 0.0001), postmenopausal women (P = 0.0001)and non-pregnant premenopausal women (P = 0.03). Local anaesthetic solutions that contain sugar (glucose or dextrose) were all hyperbaric. In the absence of sugar, all local anaesthetic solutions were hypobaric except for lidocaine CO 2 which was slightly hyperbaric. Opioids were all hypobaric except meperidine which w~ hyperbaric. Conclusion: Pregnant women have slightly lower CSF densities than do men and postmenopausal women, and non-pregnant premanopausal women. In the absence of sugar all spinal anaesthetic solutions measured were hypobaric except for lidocaine CO 2 and meperidine, both of which were hyperbanc.

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Anaesthetists are responsible for the management of the airway in patients with unstable cervical spines. Unfortunately, the anaesthetic literature does not contain a recent, critical analysis of the current medical literature to aid anaesthetists attending such patients. This review is intended to serve such a purpose. Using the Index Medicus as a guide, 30 years of medical literature were reviewed, with emphasis on the last ten years. Key words employed for this review are cited in the manuscript. Relevant papers were selected from anaesthetic, orthopaedic, rheumatologic, emergency medicine and trauma journals and reviewed. Relevant findings included the high prevalence of cervical spinal instability in such disorders such as Trisomy 21 and rheumatoid arthritis and the relatively low incidence after trauma. There are deficiencies in the minimalist approaches to assessing the cervical spine, such as a simple cross table lateral radiograph after trauma, as they are neither sensitive nor specific. Finally, recognizing the potential for instability and intubating with care, while avoiding spinal movement, appears to be more important than any particular mode of intubation in preserving neurological function.

Airway and respiratory management following non-lethal hangingPurpose: q~ review the literature on airway and respiratory management following non-lethal (suicidal) hangang and to describe the anatomy, injury and pathophysiological sequelae and their impact on patient care. Source: A IVedline literature search of English-language and English-abstracted papers for 1990-96. Keywords were: hanging; strangulation; airway obstruction; pulmonary oedema, filters were applied to limit the search to relevant citations. (i.e., keywords = pulmonary oedema; filters = postobstructive, neurogenic). C~ations were then hand-culled to obtain current and relevant papers about an unusual cohort of paaents. A hand search of the bibliographies of relevant papers supplemented the Medline search. A review of our experience at the University of Ottawa adult hospitals over the last decade was also undertaken to determine the relevance of the Irterature to our clinical experiences. Principal Findings: Most victims are young men and survwors are uncommon. Laryngo-tracheal injuries, although reported in 2,3-50% of postmortem examinations, are infrequent in survivors and have little impact on airway management. Spinal injuries are rare in survivors but should be excluded. Pulmonary complications including pulmonary oedema and I~ronchopneumonia are implicated in most in-hospital deaths. Pulmonary oedema is likely due to neurogenie factors c,r negative intrathoracic pressure. Although neurological injury determines outcome following hanging, initial neurological presentation is of limited prognostic value: a poor initial condition does not exclude a good recovery. Conclusion: Airway ~njuries severe enough to interfere with airway management are uncommon after attempted suicide by hanging. Irrespective of the initial neurological assessment, aggressive and early resuscitation to optimize cerebrai oxygenation is recommended.Objectif : PEviser ia I~Erature publiEe sur la gestion des voies a&iennes et de la respiration apt& r&hec de suicide par pendaison et dEcrire i'anatomie, les lesions et les sEquelles physiopathologiques consEcutives et leur influence sur le traitement. Source : Ure recherche sur Nledline des articles et des rEsumEs pubtiEs en langue anglaise de 1990 ,~ 1996. Les roots clEs recherchEs Etaient : pendaison ' , strangulation ; obstruction des voies aEriennes ' , oed&ne pulmonaire. Des ,,filtres,, ont E16 utilisEs pour limiter la recherche aux citations pertinentes (par ex., pour les mots des : oedEme putmonare ; les liltres postobstruction et neuro~ne). Les citations ont alors Et6 triEes ~ la main pour acquErir les articles courants et at:propriEs au sujet de cette cohorte inhabituelle de patients. Une recherche visuelle darts la bibliographie des articles i~rtinents a complEtE la recherche dans Medtine. Eexp&ience clinique accumulEe darts les hEpitaux d'adultes de runiversit6 d'Ottawa a aussi Et6 analys~e pour determiner sa concordance avec celle de la littErature. Principales constatations : La ptupart des victimes sont des ho...

BackgroundThe objective of this study was to compare the effect of thoracic paravertebral block (TPVB) and local anesthetic (LA) on persistent postoperative pain (PPP) 1 year following breast cancer surgery. Secondary objectives were to compare the effect on arm morbidity and quality of life.MethodsWomen scheduled for elective breast cancer surgery were randomly assigned to either TPVB or LA followed by general anesthesia. An NRS value of >3 at rest or with movement 1 year following surgery defined PPP. Blinded interim analysis suggested rates of PPP much lower than anticipated, making detection of the specified 20 % absolute reduction in the primary outcome impossible. Recruitment was stopped, and all enrolled patients were followed to 1 year.ResultsA total of 145 participants were recruited; 65 were randomized to TPVB and 64 to LA. Groups were similar with respect to demographic and treatment characteristics. Only 9 patients (8 %; 95 % CI 4–14 %) met criteria for PPP 1 year following surgery; 5 were in the TPVB and 4 in the LA group. Brief Pain Inventory severity and interference scores were low in both groups. Arm morbidity and quality of life were similar in both groups. The 9 patients with PPP reported shoulder-arm morbidity and reduced quality of life.ConclusionsThis study reports a low incidence of chronic pain 1 year following major breast cancer surgery. Although PPP was uncommon at 1 year, it had a large impact on the affected patients’ arm morbidity and quality of life.

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Elective oral tracheal intubation in cervical spine-injured adultsThe optimal mode of tracheal intubation in the patient with an unstable cervical spine is controversial. Turner and Joyce criticized the use of both oral tracheal intubation and in-line stabilization for cervical spine immobili-1991 / 38:6 t pp785-9