We evaluated the efficacy of intravenous lidocaine, with and without a tourniquet, to decrease the intensity of pain during intravenous propofol injection in 82 patients undergoing general anesthesia. Patients in group A (n = 20) received propofol (2 mg/kg IV); patients in group B (n = 22) received 2% lidocaine (100 mg IV) followed 1 min later by propofol (2 mg/kg). Patients in group C (n = 21, saline placebo) and D (n = 19, 2% lidocaine) had an arm tourniquet inflated to 50 mm Hg applied for 1 min after gravity drainage of venous blood. The intensity of pain along the forearm was marked on a 0-100-mm visual analogue scale. Pain intensity was less in group B (21 +/- 19 mm) than in group A (75 +/- 28 mm; P less than 0.05). Pain intensity was significantly less in group D (1 +/- 2 mm) compared with group B (21 +/- 19 mm; P less than 0.001). We conclude that intravenous lidocaine before propofol injection attenuates the painful response; whereas, lidocaine administered after a tourniquet inflated to 50 mm Hg for 1 min virtually abolishes the pain associated with intravenous propofol.

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Sevoflurane breakdown in desiccated absorbents is expected to result in only mild carbon monoxide (CO) exposure. Completely dry absorbent and high minute ventilation rates may degrade sevoflurane to extremely large CO concentrations. Serious CO poisoning or spontaneous ignition of flammable gases within the breathing circuit are possible in extreme circumstances.

Anesthesiology residents in the United States (US) not only must develop the clinical skills needed to provide independent patient care, but also are required to become familiar with the business aspects of the modern health care system. Unfortunately, practice management education may be inadequate during anesthesiology residency training. The authors describe the design and implementation of a weekend retreat curriculum in business-of-medicine education for anesthesiology residents. Experts were recruited to discuss interviewing skills, contract law and negotiation, billing and reimbursement, insurance, malpractice, and financial planning. A strict lecture didactic format was avoided, and presentations were designed to encourage speaker-audience interaction. The program was relatively simple to design and implement, satisfied several Accreditation Council of Graduate Medical Education core competencies for US anesthesiology education, may be altered as practice management evolves, and may be adapted to accommodate the needs of programs in other countries.

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Klippel-Trénaunay syndrome is a rare disorder characterized by the triad of capillary or cavernous hemangiomas, venous varicosities or malformations, and soft tissue or bone hypertrophy. Neuraxial anesthesia in patients with Klippel-Trénaunay syndrome has been infrequently described and has not been previously reported when accompanied by consumptive coagulopathy with thrombocytopenia (Kasabach-Merritt syndrome). The authors describe their clinical management of a 23 year-old woman with Klippel-Trénaunay syndrome who presented for elective total knee arthroplasty. Her past medical history was notable for chronic Kasabach-Merritt syndrome, hypersplenism with pancytopenia, and intermittent lower gastrointestinal bleeding resulting from colonic hemangiomas. The physical examination revealed several large cavernous hemangiomas located on her right face, neck, chest, arm, and leg. No hemangiomas were noted within the dermatomal levels innervated by the upper lumbar spine. The neck hemangioma was very large and filled with blood when the patient assumed a supine position, making it almost impossible for her to breathe. The oropharynx revealed markedly hypertrophied soft tissue, pharyngeal, and hypopharyngeal hemangiomas, and a Mallampati class IV airway. Spinal and epidural hemangiomas were excluded based on a magnetic resonance imaging study before surgery. Kasabach-Merritt coagulopathy was corrected preoperatively by administration of cryoprecipitate. These interventions allowed the authors to safely perform a spinal anesthetic for the operation. The current case illustrates that major conduction anesthesia may be safely performed in patients with Klippel-Trénaunay disease provided that preoperative imaging studies exclude neurovascular involvement and coexisting coagulopathy is appropriately corrected.

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Hormis l 'article de Sia et coll.,4 Electroconvulsive therapy-induced asystole: occurrence after 39 previous uneventful treatmentsTo the Editor: Asystole (defined as an absence of heartbeat for five or more seconds) is an unusual but increasingly recognized complication of electroconvulsive therapy (ECT) in older patients. 1,2 We recently provided care for a 73-yr-old man with major depression including psychotic and catatonic features who was admitted for outpatient ECT. The patient had undergone a series of 39 previous uncomplicated ECTs under general anesthesia over the previous six months, and had experienced an excellent clinical response. The patient was treated with maintenance ECT on a weekly basis, and also received chronic oral venlafaxine (300 mg·day -1 in divided doses) and aripiprazole (30 mg·day -1 in divided doses) therapy. Sodium thiopental (dose range of 1.5 to 2 mg·kg -1 ) and succinylcholine (1 to 1.5 mg·kg -1 ) were used for anesthesia, and labetalol (10 to 20 mg) or esmolol (50 to 100 mg) were used to control sympathetic nervous system stimulation during most of the previous treatments. The patient also had a past history of coronary artery disease, poorly controlled essential hypertension, and hyperlipidemia treated with oral enteric aspirin (325 mg·day -1 ), clopidogrel (75 mg·day -1 ), isosorbide mononitrate (30 mg·day -1 ), lisinopril (20 mg·day -1 ), and simvastatin (80 mg·day -1 ). A preoperative electrocardiogram indicated normal sinus rhythm with occasional premature ventricular contractions, voltage criteria for left ventricular hypertrophy, and nonspecific T wave abnormalities. These findings were stable, and no conduction abnormalities were present. The serum potassium concentration was 4.4 mEq·L -1 . The remainder of the laboratory analysis was normal.In anticipation of a hyperdynamic cardiovascular response to ECT, preoperative hypertension was treated with labetalol (20 mg iv in divided doses). Anesthesia was induced using sodium thiopental 2 mg·kg -1 iv and succinylcholine 1 mg·kg -1 iv after placement of transcutaneous bilateral cranial electrodes. An oral airway was placed, positive pressure ventilation by mask was begun using 100% oxygen, and ECT was induced (95% energy; total delivered charge of 479 mCoulomb; total seizure duration of 35 sec). Asystole was noted on the continuous electrocardiogram concomitant with the loss of the pulse oximetry and capnography signals immediately after the onset of the electrical stimulus. Radial and carotid arterial pulses were absent, chest compressions were initiated, and atropine (0.6 mg iv) was administered. Ventricular bigeminy was observed almost immediately after chest compressions were begun, lidocaine 100 mg iv was administered, and normal sinus rhythm was restored. The asystole was approximately ten seconds in duration. Arterial blood gas analysis and serum electrolyte concentrations obtained after the episode were normal. The patient emerged from anesthesia without difficulty and was drowsy but easily aroused during the first ...