Bolus doses of propofol in patients for cardioversion often produce hypotension and apnea. Etomidate provides cardiovascular stability in these patients, but myoclonus may interfere with electrocardiographic interpretation. This study was designed to demonstrate whether propofol, when given as a low-dose infusion, can attain etomidate's hemodynamic stability without its attendant side effects. Forty consenting patients were randomly assigned to receive either propofol infusion (50 mg/min) for induction of anesthesia followed by a maintenance infusion (100 micrograms.kg-1.min-1) or etomidate (8 mg/min and 20 micrograms.kg-1.min-1). Calculation of loading infusion rates for propofol and etomidate resulted in averages of 0.64 mg.kg-1.min-1 (range, 0.39-1.04) and 0.09 mg.kg-1.min-1 (range, 0.05-0.14), respectively. Induction times (2.2 min) and the times from terminating drug administration to awake states (4.5 min) were similar for each group. Etomidate produced myoclonus in 45% of the patients; otherwise side effects were minimal, with no significant differences between groups. The means of systolic blood pressures in the etomidate group rose a maximum of 15.3 +/- 7.9% (95% confidence), while a modest decrease of 7.2 +/- 7.3% occurred with propofol. Administration of propofol by infusion for cardioversion retains all its beneficial qualities while attenuating its hypotensive effects, making it a suitable choice for these patients with cardiac arrhythmias.

ostdural puncture headache (PDPH) is a wellrecognized complication after spinal anesthesia P (1). When conservative treatment or epidural blood patch (EBP) fail, alternative causes of the headache need to be reconsidered. We present a previously unreported association of recurrent PDPH with a Chiari I malformation. Case ReportA 31-yr-old woman (gravida 1, para 0), with an unremarkable medical history, received analgesia for labor via a lumbar epidural catheter. Subsequently, when she required cesarean section for failure of the labor to progress, satisfactory lumbar epidural anesthesia could not be established. Good surgical anesthesia was provided by subarachnoid block, although spinal needle placement proved technically difficult and required several attempts before successful dural puncture with a 22-gauge needle. The surgery and immediate postoperative period were uneventful. Although she reported a mild positional headache, her surgeon discharged her on the third postoperative day. However, over the following several days, the patient's headache became progressively more severe. The headache was associated with mild neck pain, which worsened when the patient was sitting or standing. Moderate relief was obtained by caffeine ingestion. On the sixth postoperative day, although afebrile, she developed hearing changes (echoing), visual disturbances (blurring and color distortion), and nausea. The diagnosis of PDPH was made. An EBP using 15 mL of autologous blood was administered, with marked improvement of all symptoms.The patient had a recurrence of the headache 4 days

To compare the efficacy of patient-controlled lumbar and thoracic epidural sufentanil, 22 patients scheduled for elective thoracotomy were assigned randomly to receive sufentanil via either a lumbar or a thoracic epidural catheter. For 24 h postoperatively, the patients received analgesia only by patient-controlled epidural sufentanil. There were no significant differences in the visual analog scale (VAS) for pain between the two groups at 8 and 24 h postoperatively. Nausea and pruritus were minimum, requiring treatment less than once per 24-h period in either group. The forced vital capacity (FVC) measured at 24 h (as a percentage of baseline FVC) showed no significant difference between the lumbar and thoracic groups (44.7 +/- 3.8 and 41.7 +/- 5.5; P = 0.68). The total sufentanil used by the lumbar and thoracic groups was not significantly different (196 +/- 25.2 micrograms and 157 +/- 28.6 micrograms; P = 0.32). We conclude that there is no clinical advantage of thoracic over lumbar epidural sufentanil in the thoracotomy patient with respect to quality of analgesia, amount of sufentanil used, severity of side effects, or postoperative pulmonary function.

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