COMMUNICATIONS IN BRIEF
This section is suitable for reponing cases, results of therapeutic trials, and descrip· tions of new procedures or instruments. Reports should be limited to seven hundred words and two references. Use of an illustration or table requires a proportionate reduction in total words.
Spinal anesthesia for laparoscopic tubal sterilization D. CACERES K. KIM
Indiana University School of Medicine, Indianapolis, Indiana
with controlled ventilation laparoscopy and transecfor has been recommended tion of the Fallopian tubes. The use of spinal anesthesia has never been reported and its use for this procedure has been contraindicated because of the position of the patient, the distention of the abdominal cavity by the insufflation of carbon dioxide, the absorption of this into the bloodstream, and patient discomfort. Fifteen patients undergoing laparoscopic sterilization were selected at random. Mean age was 33 ± 4 years, and mean weight was 125 ± 21 pounds. All patients were American Standards Association Class I. Premedication consisted of morphine sulfate, 0.065 mg. per pound of body weight. The patients were monitored with electrocardiograms and blood pressure by cuff and chest stethoscope. A radial artery was cannulated with the use of local anesthesia, and 10 minutes later, while the patients were breathing room air, arterial samples were taken. Spinal anesthesia was then induced with a 25 gauge spinal needle placed at the level of the fourth to fifth lumbar vertebra and hyperbaric lidocaine, 75 mg. injected intrathecally. Following the carbon dioxide insufflation, arterial samples were drawn at five, 10, and 15 minutes, as well as after the patients had been in the recovery room for 30 minutes. All patients breathed room air during the entire procedure. The amount of carbon dioxide insufflated was 3.5 ± 1.2 L. Mean in-
GENERAL ANESTHESIA
Reprint requests: D. Caceres, Indiana University School of Medicine, ll 00 W. Michigan St., Indianapolis, Indiana 46202. 0002-9378/78102131-0219$00.2010
©
1978 The C. V. Mosby Co.
traperitoneal pressure was 10 ± 4 mm. Hg. All patients were kept in a 15° Trendelenburg position. After the carbon dioxide insufflation, intraperitoneal pressure rose by 10 mm. Hg and systolic and diastolic pressures also increased by 13 and 17 mm. Hg, respectively. No arrhythmia was observed. The mean Pa 0 , before the block was 77.4 mm. Hg; it rose to 90 and 93.3 mm. Hg five and 15 minutes after insufflation. The increases in Pa 0 , were statistically significant (p < 0.001). Pac 0 , values did not change significantly. pH values were decreased by 0.03. Three patients complained of pain in the right shoulder as the carbon dioxide was being insufflated. The pain subsided after the insufflation was slowed and I c.c. of fentanyl* was administered intravenously. It was interesting to see that the mean Pa 0 , was significantly increased while the Pac 0 , slightly changed despite the distention of the abdominal cavity, the head-down position, high level of spinal anesthesia, and breathing of room air. This could be explained on the basis that the respiratory center was not depressed and responded to the carbon dioxide. The fact that a sensory block up to the level of the fifth to sixth thoracic vertebra did not prevent the shoulder pain, indicates that it comes from the diaphragmatic area. It is concluded that, in the healthy patient who is going to undergo laparoscopy, spinal anesthesia could be another alternative to general anesthesia. *Innovar, McNeil Labs., Inc., Fort Washington, Pennsylvania.
REFERENCES 1. Baratz, R. A., and Karis, J. H.: Blood gas studies during laparoscopy under general anesthesia, Anesthesiology 30: 463, 1969. 2. Siegler, A.M., and Berenyi, K. ].: Laparoscopy in gynecology. Obstet. Gynecol. 34: 572, 1969. 3. Berenyi, K. j., Fujita, T., and Siegler, A. M.: Carbon dioxide Japaroscopy. Anesthetic management and deter219
220
Communications in brief Am.
ruinations of acid-base parameters, Acta Anaesthesia!. Scand. 14: 77, 1970. 4. Desmond, J., and Gordon, R. A.: Ventilation in patients anesthetized for laparoscopy, Can. Anaesth. Soc. J. 17: 378, 1970. 5. Seed, R. F., Shakespeare, T. F., and Muldoon, M. J.: Carbon dioxide homeostasis during anesthesia for laparoscopy, Anesthesia 25: 223, 1970. 6. Perel, M. K.: Anesthesia para celioscopia, Rev. Obstet. Ginecol. Ven. 23: 489, 1963.
J.
May 15, 1978 Obstet. Gynecol.
and Clewe!J2 reported an identical case in 1974; however, the disruption was caused by amniocentesis. No report could be found of spontaneous or unexplained rupture of a placental vessel.
disruption of the placental vein is speculative. In the case reported here, there was no history of maternal abdominal trauma. A case with pathologic features similar to those of the present case was cited by Buchsbaum,1 in 1968, but disruption of the placental vessel was secondary to trauma. Goodlin
A 29-year-old woman, gravida 4, para 3, was admitted to the hospital on January 20, 1976, at 39 weeks' gestation , for an elective repeat cesarean section . Her pregnancy had been free of complications, and the highest blood pressure had been 120/80. In 1971, she had a cesarean section for fetal distress: prior to that she had had two term vaginal deliveries. On J anuary 21, 1976, about six hours before the intended repeat cesarean section was scheduled, the patient's sleep was interrupted by a sudden gush of bloody amniotic fluid . The cervix was 2 em. dilated and uneffaced. The vertex was at the -2 station. The uterus was soft and nontender, and the fetal heart tones were audible in the right lower abdomen. The blood pressure was 130/86, and pulse was 72 beats per minute. Hemoglobin was 11.5 Gm. per 100 mi. and the hematocrit was 34.5 per cent. An emergency cesarean section was begun immediately, and a healthy, but pale, female infant was delivered, with Apgar scores of 7 and 8 at one and five minutes, respectively. The placenta, implanted in the posterior fundus, appeared entirely normal except for a small opening in a blood vessel, !.5 em. from the insertion of the cord (Fig. l); there was active bleeding from this defect in a blood vessel on the fetal surface of the placenta (Fig. 2). Microscopic examination of the placenta revealed the lacerated vessel to be a vein. The umbilical cord was normal microscopically, as was the placenta.
Reprint requests: Dr. William A. Cook, Department of Obstetrics and Gynecology, Akron General Medical Center, Akron, Ohio 44307.
In the case reported here, the normal placental vein either ruptured spontaneously or was lacerated by the fetus. It is of interest that the infant's fingernails were
Laceration of a placental vein: An injury possibly inflicted by the fetus ALLEN Q . TUGGLE , M.D. WILLIAM A . COOK, M.D .
Deparlmem of Obstetrics and Gynecowgy, Northeastern Ohio Universities College of Medicine, and Akron General Medical Center, Akron, Ohio THE MECHANISM OF
Fig. 1. Fetal surface of the placenta, with ruptured vessel shown at arrow. 0002-9378178/02131-0220$00.20/0 ©1978 The C. V. Mosby Co.
This section is suitable for reponing cases, results of therapeutic trials, and descrip· tions of new procedures or instruments. Reports should be limited to seven hundred words and two references. Use of an illustration or table requires a proportionate reduction in total words.
Spinal anesthesia for laparoscopic tubal sterilization D. CACERES K. KIM
Indiana University School of Medicine, Indianapolis, Indiana
with controlled ventilation laparoscopy and transecfor has been recommended tion of the Fallopian tubes. The use of spinal anesthesia has never been reported and its use for this procedure has been contraindicated because of the position of the patient, the distention of the abdominal cavity by the insufflation of carbon dioxide, the absorption of this into the bloodstream, and patient discomfort. Fifteen patients undergoing laparoscopic sterilization were selected at random. Mean age was 33 ± 4 years, and mean weight was 125 ± 21 pounds. All patients were American Standards Association Class I. Premedication consisted of morphine sulfate, 0.065 mg. per pound of body weight. The patients were monitored with electrocardiograms and blood pressure by cuff and chest stethoscope. A radial artery was cannulated with the use of local anesthesia, and 10 minutes later, while the patients were breathing room air, arterial samples were taken. Spinal anesthesia was then induced with a 25 gauge spinal needle placed at the level of the fourth to fifth lumbar vertebra and hyperbaric lidocaine, 75 mg. injected intrathecally. Following the carbon dioxide insufflation, arterial samples were drawn at five, 10, and 15 minutes, as well as after the patients had been in the recovery room for 30 minutes. All patients breathed room air during the entire procedure. The amount of carbon dioxide insufflated was 3.5 ± 1.2 L. Mean in-
GENERAL ANESTHESIA
Reprint requests: D. Caceres, Indiana University School of Medicine, ll 00 W. Michigan St., Indianapolis, Indiana 46202. 0002-9378/78102131-0219$00.2010
©
1978 The C. V. Mosby Co.
traperitoneal pressure was 10 ± 4 mm. Hg. All patients were kept in a 15° Trendelenburg position. After the carbon dioxide insufflation, intraperitoneal pressure rose by 10 mm. Hg and systolic and diastolic pressures also increased by 13 and 17 mm. Hg, respectively. No arrhythmia was observed. The mean Pa 0 , before the block was 77.4 mm. Hg; it rose to 90 and 93.3 mm. Hg five and 15 minutes after insufflation. The increases in Pa 0 , were statistically significant (p < 0.001). Pac 0 , values did not change significantly. pH values were decreased by 0.03. Three patients complained of pain in the right shoulder as the carbon dioxide was being insufflated. The pain subsided after the insufflation was slowed and I c.c. of fentanyl* was administered intravenously. It was interesting to see that the mean Pa 0 , was significantly increased while the Pac 0 , slightly changed despite the distention of the abdominal cavity, the head-down position, high level of spinal anesthesia, and breathing of room air. This could be explained on the basis that the respiratory center was not depressed and responded to the carbon dioxide. The fact that a sensory block up to the level of the fifth to sixth thoracic vertebra did not prevent the shoulder pain, indicates that it comes from the diaphragmatic area. It is concluded that, in the healthy patient who is going to undergo laparoscopy, spinal anesthesia could be another alternative to general anesthesia. *Innovar, McNeil Labs., Inc., Fort Washington, Pennsylvania.
REFERENCES 1. Baratz, R. A., and Karis, J. H.: Blood gas studies during laparoscopy under general anesthesia, Anesthesiology 30: 463, 1969. 2. Siegler, A.M., and Berenyi, K. ].: Laparoscopy in gynecology. Obstet. Gynecol. 34: 572, 1969. 3. Berenyi, K. j., Fujita, T., and Siegler, A. M.: Carbon dioxide Japaroscopy. Anesthetic management and deter219
220
Communications in brief Am.
ruinations of acid-base parameters, Acta Anaesthesia!. Scand. 14: 77, 1970. 4. Desmond, J., and Gordon, R. A.: Ventilation in patients anesthetized for laparoscopy, Can. Anaesth. Soc. J. 17: 378, 1970. 5. Seed, R. F., Shakespeare, T. F., and Muldoon, M. J.: Carbon dioxide homeostasis during anesthesia for laparoscopy, Anesthesia 25: 223, 1970. 6. Perel, M. K.: Anesthesia para celioscopia, Rev. Obstet. Ginecol. Ven. 23: 489, 1963.
J.
May 15, 1978 Obstet. Gynecol.
and Clewe!J2 reported an identical case in 1974; however, the disruption was caused by amniocentesis. No report could be found of spontaneous or unexplained rupture of a placental vessel.
disruption of the placental vein is speculative. In the case reported here, there was no history of maternal abdominal trauma. A case with pathologic features similar to those of the present case was cited by Buchsbaum,1 in 1968, but disruption of the placental vessel was secondary to trauma. Goodlin
A 29-year-old woman, gravida 4, para 3, was admitted to the hospital on January 20, 1976, at 39 weeks' gestation , for an elective repeat cesarean section . Her pregnancy had been free of complications, and the highest blood pressure had been 120/80. In 1971, she had a cesarean section for fetal distress: prior to that she had had two term vaginal deliveries. On J anuary 21, 1976, about six hours before the intended repeat cesarean section was scheduled, the patient's sleep was interrupted by a sudden gush of bloody amniotic fluid . The cervix was 2 em. dilated and uneffaced. The vertex was at the -2 station. The uterus was soft and nontender, and the fetal heart tones were audible in the right lower abdomen. The blood pressure was 130/86, and pulse was 72 beats per minute. Hemoglobin was 11.5 Gm. per 100 mi. and the hematocrit was 34.5 per cent. An emergency cesarean section was begun immediately, and a healthy, but pale, female infant was delivered, with Apgar scores of 7 and 8 at one and five minutes, respectively. The placenta, implanted in the posterior fundus, appeared entirely normal except for a small opening in a blood vessel, !.5 em. from the insertion of the cord (Fig. l); there was active bleeding from this defect in a blood vessel on the fetal surface of the placenta (Fig. 2). Microscopic examination of the placenta revealed the lacerated vessel to be a vein. The umbilical cord was normal microscopically, as was the placenta.
Reprint requests: Dr. William A. Cook, Department of Obstetrics and Gynecology, Akron General Medical Center, Akron, Ohio 44307.
In the case reported here, the normal placental vein either ruptured spontaneously or was lacerated by the fetus. It is of interest that the infant's fingernails were
Laceration of a placental vein: An injury possibly inflicted by the fetus ALLEN Q . TUGGLE , M.D. WILLIAM A . COOK, M.D .
Deparlmem of Obstetrics and Gynecowgy, Northeastern Ohio Universities College of Medicine, and Akron General Medical Center, Akron, Ohio THE MECHANISM OF
Fig. 1. Fetal surface of the placenta, with ruptured vessel shown at arrow. 0002-9378178/02131-0220$00.20/0 ©1978 The C. V. Mosby Co.
