Download Update 11 - Update in Anaesthesia - WFSA

66Update in Anaesthesiabefore and the tip will end posterior to the femur. This I would like to acknowledge the kind assistance of Drmay help find the nerve, which tends to lie slightly behind Barry Nicholls for advice, particularly with regard to thethe femur at this level. (When using this more medial block techniques and Dr Kristine Barnden for proofinjection point, it may help to place the free hand under reading the manuscript.the buttock and palpate the ischial tuberosity. The needleReferencesis then aimed at a point estimated to be 1 - 2cm lateral to1. Selander D., Dhuner K.E. and Lundberg E. Peripheral nervethe ischial tuberosity.)injuries due to injection needles used for regional anaesthesia.Performing a sciatic nerve block using a nerve Acta Anaesthesiologica Scandinavica 1977; 21: 182.stimulator A nerve stimulator may be used in 2. Khoo S.T. and Brown T.C.K. Femoral nerve block - theconjunction with any of the approaches to the sciatic anatomical basis for a single injection technique. Anaesthesianerve that have been described above. The techniques and Intensive Care 1983; 11: 40-2.for determining the point of injection and locating the 3. Winnie A.P., Ramamurthy S. and Durrani Z. The inguinalnerve are no different, except that one will look for paravascular technic of lumbar plexus anaesthesia. The “3-in-1muscle contraction. The best indicator of proximity Block.” Anesthesia and Analgesia 1973; 52: 989-96.to the nerve is dorsiflexion of the foot at the ankle and 4. Dalens B., Tanguy A. and Vanneuville G. Sciatic nerve blocksone should aim to achieve this at a stimulating current in children: Comparison of the posterior, anterior and lateralapproaches in 180 paediatric patients. Anaesthesia and Analgesiaof 0.3 - 0.5 mA. However, when using the posterior1990; 70: 131-7.approaches, one may also see contraction of the5. Labat G. Regional Anaesthesia, Its Technique and Clinical“hamstring” muscles down the back of the thigh, whichApplication. Philadelphia. W.J. Saunders. 1924may be taken as a sign of proximity to the sciatic nerve.Having achieved muscle contraction at the required Further reading:stimulating current, injection of local anaesthetic is 1. Macrae W.A. Lower Limb Blocks in Wildsmith J.A.W. andperformed in the usual manner.Armitage E.N. (eds)2. Bridenbaugh P.O. and Wedel D.J. The lower extremity - somaticAcknowledgementsblockade. In Cousins M.J. and Bridenbaugh P.O. (eds) NeuralBlockade in Clinical Anaesthesia and Management of Pain 3rded. pp 373 - 94 Lippincott-Raven 1998.CLINICAL MANAGEMENT OF DIABETES MELLITUS DURING3. Covino B.G. and Wildsmith J.A.W. Clinical pharmacology ofANAESTHESIA AND SURGERYlocal anaesthetic agents. In Cousins M.J. and Bridenbaugh P.O.(eds) Neural Blockade in Clinical Anaesthesia and ManagementDr Gordon French FRCA, Northampton General Hospital, of Northampton, Pain 3rd ed. pp UK. 97 - 128 Lippincott-Raven 1998.INTRODUCTIONDiabetes is a condition where the cells of the body cannotmetabolise sugar properly, due to a total or relative lackof insulin. The body then breaks down its own fat, proteinsand glycogen to produce sugar, resulting in high sugar levelsin the blood (hyperglycaemia) with excess by-productscalled ketones being produced by the liver.There are two main types of diabetes (table 1) whichclassically affect different age groups. In reality there is ahuge overlap between age groups.Diabetes causes disease in many organ systems, theseverity of which may be related to how long the diseasehas been present and how well it has been controlled.Damage to small blood vessels (diabetic microangiopathy)and nerves (neuropathy) throughout the body results inmany pitfalls for the unwary anaesthetist. The followingguidelines should help to identify these problems and copewith them.Preoperative assessment. The general preoperativeassessment has been reviewed in a previous article. Updatein Anaesthesia in 1997;7.Specific problems arise:Cardiovascular- diabetics are more prone tohypertension, ischaemic heart disease, cerebrovasculardisease, myocardial infarction which may be silent andcardiomyopathy. Damage to the nerves controlling theheart and blood vessels (autonomic neuropathy) may resultin sudden tachycardia, bradycardia or a tendency topostural hypotension. A history of shortness of breath,palpitations, ankle swelling, tiredness and of course chestpain should therefore be sought and a careful examination