Diazepam and Local Anesthesia in Anorectal Surgery* ,JOUN M. MUSGRAVE, M.D.,t rW. PATRICK MAZIER, M.D. + From the Ferguson Clinic, Grand Rapids, Michigan

MANY TYeES of anesthesia are available for anorectal surgical procedures. General and spinal anesthesia have been most widely used, and have proven to be very satisfactory. Local anesthesia combined with intramuscular or intravenous analgesics has also been used, and has been shown to be extremely effective. This report concerns the use of a local anesthetic combined with other drugs as one method for anorectal surgery tha, t can be particularly effective and easily adapted to most situations. Materials

2.5 to 30 mg. Eighty-eight patien, ts (48 per cent required only 10 mg or less. Of the 161 consecutive procedures using intravenously administered diazepam combined with local anesthetic, 73 were hemorrhoidectomies; 27, transrectal polypectomies; 15, sutures of posthemorrhoidectomy wounds; five, hemorrhoidectomy and listulectomy: four, anal ulcerectomies; four, superficial anal sphincterotomies, four anal fistulectomies; three pilonidal cystectomies; three, incision and drainage abscesses; three excisions of anal papillae; 18, other assorted procedures. Indications

In September 1972, one of the authors began using diazepam (Valium), administered intravenously combined with lidocain (Xylocaine), and 0.5 per cent, and epinephrine, 1:200,000, locally injected into the perianum, for a variety of anorectal cases. From September 1972 to December 1974, 7,585 anorectal operations were done at the Ferguson Clinic. Diazepare with perianal injection of local anesthetic was used in 161 procedures (2.1 per cent). This report describes the method and results of those 161 procedures. T h e 159 pa,tients in this study ranged in age from 18 to 86 years. T h e average age was 54 years, with 77 male and 82 female p~tients. Doses of diazepam ranged from

Severe anxiety over general or spi,nal anesthesia was the most frequen, t indication. Medical problems leading to selection of this method included hypertension, obesity, diabetes mellitus, chronic obstructive pulmonary disease, failure of a.ttempted spinal anesthesia, coronary insufficiency, chronic congestive heart failure, history of myocardial ir~farction, and multiple sclerosis. T h e procedure is also recommended for very old patients. Method

Preoperatively, in these selected cases, the surgeon discussed wi.th the patient the use of diazepam and local anesthesia. This method was also discussed by the anesthesiologist during his routine preoperative interview wi,th the patient. T h e patient was given standard preoperative medication, usually morphine and atropine. In the operating roonl, diazepam was given in 2.5- or 5-mg incremen,ts in.travenously until

* R e a d at t h e m e e t i n g of t h e American Society of Colon a n d Rectal Surgeons, San Francisco, California, May 4 to 8, 1975. t Resident Staff. ~. Active Staff. Address r e p r i n t requests to Dr. Musgrave: Ferguson Clinic, 72 Sheldon Avenue, S.E., G r a n d Rapids, Michigan 49502.

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satisfactory sedation was obtained. Lidocaine with epinephrine was injected in and about the operative site, using 60-80 ml of solution. (With general or spinal anesthesia, the amount of local anesthetic solution used is only 40-50 ml. Following the surgical procedure, the patient either went to the postanesthesia recovery room or was returned directly to his room. Results T w e n t y of the 161 patients (12.4 per cent) needed additional medication. Meperidine was given in,travenousIy in 13 cases (8.1), with dosages ranging from 30 to 100 mg. These cases included four hemorrhoidectomies, two hemorrhoidectomy and fistulectomy, three resutures of post hemorrhoidectomy wounds, two incisions and drainages o[ abscesses, one transrectal polypectomy, and one excision of perianal lesion. In seven cases a light level of general anesthesia was needed; in these cases methoxyflurane, thiopentaI, nitrous oxide, or hatothane was used. These included three hemorrhoidectomies, one resu.ture of a post hemorrhoidectomy wound, two transrectal polypeetomies and one anoplasty. No complication resulted from the use of intravenously adminis,tered diazepam. Discussion In recent years many investiga,tors have advocated the use of intravenously administered diazepam for various procedures, including bronchoscopy? cardiac catheterization,2 cystoscopy,S and reductions of fractures and disloca.tions.6 As is well known, diazepam is a benzodiazepine derivative a whose primary site o[ action is the brain-stem reticular formation. Loudin, in 1960, reported the calming effect of this drug on monkeys, and he presented the first clinical study of its effects in 1961. Electroencephalographic studies show a characteristic decrease in the alpha rhythm

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pattern. Diazepam is excreted via the kidneys, and i,ts basic effect is that of sedation and musculoskeletaI relaxtion. Some of its undesirable side effects have been described as central nervous system depression, extreme lethargy, and inappropriate excitement. Although complications in the use of this drug for surgical procedures have been reported, 4. 7 no complication was encountered in our series of 161 procedures. T h e use of local anesthesia as a supplemen, t to general anesthesia has been very successful in proctologic procedures for many years at the Ferguson Clinic. T h e addition of epinephrine, 1:200,000, greatly enhances the action of lidocaine and reduces blood loss considerably. T h i s very dilute solution of epinephrine produces practically no systemic effect. It has been the experience of the authors that combining local injeGtion of lidocaine and epinephrine with diazepam provides ideal anesthesia for patients in the poor-risk categories and for those who have severe anxiety concerning general or spinal anesthesia. In the properly prepared and conditioned patient, this mode of anesthesia is extremely safe and easy to administer. We have found also that use of intravenously administered diazepam with local anesthesia is very poorly tolerated if the patient is inadequately prepared for this type of anesthesia before being brought to the surgical area. T h i s was certainly the case in the 20 procedures in which the patients needed additional anesthetic agents. T h e patients best suited to this approach were those willing to accept it because of its safety and well prepared and condi, tioned preoperatively. Another very i m p o r t a n t factor is how well the anesthesiologist is disposed toward this type of program. We have found that some who are enthusiastic about the procedure have little difficuky, while others seem to transmit their uneasiness about the procedure to the patient.

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References

Summary A t the F e r g u s o n Clinic, 161 a n o r e c t a l procedures utilizing intravenously administered d i a z e p a m a n d l i d o c a i n e 0.5 p e r cent, w i t h e p i n e p h r i n e , 1:200,000, wer done. Of the p a t i e n t s so treated, 12 per cent n e e d e d a d d i t i o n a l m e d i c a t i o n in o r d e r for anesthesia to be effective. N o c o m p l i c a t i o n resul.ted f r o m the use of these c o m b i n a t i o n s . I t is r e c o m m e n d e d that the c o m b i n a t i o n of i n t r a v e n o u s l y a d m i n i s t e r e d d i a z e p a m w i t h local i n j e c t i o n of l i d o c a i n e a n d epin e p h r i n e be given w i d e r usage because of its ease of h a n d l i n g a n d very low comp l i c a t i o n rate.

1. Cianculli FD: Diazepam for bronchoscopy (letter to editor). Chest 64: 280, 1973 2. Dalen JE, Evans GL, Banas JS Jr, et al: The hemodynamic and respiratory effects of diazepam (Valium). Anesthesiology 30: 259, 1969 3. Goodman LS, Gilman A: The Pharmacological Basis of Therapeutics. Fourth edition. New York, 1970, pp 122; 132; 179 4. Hines RA: Carpal tunnel syndrome and diazepare (intravenously) (letter to editor). JAMA 228: 697, 1974 5. Metz P, Halveg JO: Pethidine--diazepam analgesia for cystoscopy. Anaesthesia 29: 92, 1974 6. Mouzas GL: Diazepam used intravenously during reduction of fractures and dislocations. Practitioner 21 l: 805, 1973 7. Taylor PA, Cotton PB, Towey RM, et al: Pulmonary complications after oesophagogastroscopy using diazepam. Br Med J 1: 666, 1972

Announcement 4th World Congress Collegium Internationale Chirurglae Digestivae Davos, Switzerland, 8-9-10-I 1-12 September, 1976

Main Topics: Liver resection (lecture), J. L. Lortat-Jacob, Paris, France. Operations for obesity (lecture). B. Husemann, Erlangen, Germany. Transsphincteral approach to the anorectal canal (lecture), A. YI Mason, London, Great Britain. Treatment ot inflammatory bowel disease (panel-session), Moderator: L. Thor6n, Uppsala, Sweden. Reoperative surgery of the biliary tract (panel-session), Moderator: J. Hepp, Paris, France. Operative tactics when facing gastric carcinoma (panel-session), Moderator: W. l,ongmire, Los Angeles, Cal., U.S.A. Proximal selective vagotomy (panel-session), Moderator: J. Alexander-Williams, Birmingham, Great Britain. For a preliminary program and further information please contact Th. P. Rtiedi, M.D., Secretary General, Department ffir Chirurgie, Kantonsspital, CH-4004, Basel, Switzerland.

Diazepam and local anesthesia in anorectal surgery.

At the Ferguson Clinic, 161 anorectal procedures utilizing intravenously administered diazepam and lidocaine 0.5%, with epinephrine, 1:200,000, were d...
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