Anaesthesia, 2003, 58, pages 804–827
Correspondence
....................................................................................................................................................................................................................
.
No side-effects were reported from
any Group I patients. One patient from
Group II reported mild to moderate 2 Striebel HW, Koenigs D, Kramer J.
unselected population. Anaesthesia
1993; 48: 753–7.
toms. Systolic blood pressure (SBP)
was maintained between 110 and
120 mmHg throughout the test. Just
after conclusion of the test, the patient
suffered sudden and acute massive bleed-
ing from a branch of the left CCA. She
developed hypovolaemic shock (SBP
50–60 mmHg). A continuous infusion
of dopamine (5 lg.kg .min ) was star-
ted to maintain her blood pressure and
the patient was immediately scheduled to
undergo ligation of the left CCA to
control the bleeding. Anaesthesia was
maintained with fentanyl, sevoflurane
and nitrous oxide. During the operation,
when the SBP decreased below
90 mmHg (mean blood pressure 75–
pruritus.
Postoperative pain management by
intranasal demand-adapted fentanyl
titration. Anesthesiology 1992; 77:
281–5.
Mean analgesic plasma concentration
)1
of fentanyl ranges from 0.6 to 3 ng.ml
following intravenous administration
[
3]. Blood samples from patients in 3 Peng PWH, Sandler AN. A review of
)
1
)1
Group I were taken at 0, 5, 15, 30, 60
and 120 min after the first administration
of intranasal fentanyl. However, no
fentanyl was detected in any of the serum
samples.
the use of fentanyl analgesia in the
management of acute pain in adults.
Anesthesiology 1999; 90: 576–99.
Acknowledgements
This work was supported by funds from
The Friends of Guy’s Hospital, Guy’s
Hospital, London. The spray bottles
manufactured by Go Medical) were
provided by Dr Tim Craft (Royal
United Hospital, Bath).
We found no clinically relevant
intergroup difference in the measured
sedation scores, oxygen saturation, heart
rate, systolic blood pressure and respir-
atory rate (unpaired t-test with two-
sample equal variance test), VAS scores,
or amount of rescue analgesia (Fisher’s
exact test, p ¼ 0.149). However, for
this small sample of patients, the power
of this study was only 0.23.
(
80 mmHg), the value of rCsO2 of the left
side decreased 10% more than that of the
right side. Throughout the operation, we
tried to maintain SBP at more than
90 mmHg. The operation time was
10 h 12 min and that of anaesthesia was
11 h 47min. The patient was extubated
in the operating room and was dis-
charged without any sequelae.
Carotid artery ligation is sometimes
performed to control bleeding from the
head and neck [1]. The most serious
complication of this procedure is cerebral
hypoperfusion with neurological deficit
[2]. In normal human subjects, the Circle
of Willis is the most important collateral
channel for circulation in the brain. This
system has many variations and 28% of
patients have an inadequate Circle of
Willis as a channel for collateral circula-
tion [3]. Therefore, it is important to
confirm the function of this system.
Cerebral hypoperfusion with
systemic hypotension during
common carotid ligation
In conclusion, we think that our
results are encouraging. The ease of
intranasal administration, the safety of a
controlled dose and the high patient
acceptability of this method of pain
relief deserve more attention. The lack
of clinical significance between the
two groups’ VAS scores suggests that
PCINA may be as effective as intra-
muscular morphine, or may be superior
in terms of the number of patients
requiring rescue analgesia. The high
patient satisfaction with the intranasal
pain relief was also remarkable. How-
ever, the PCINA patients had a much
more frequent rate of analgesic admin-
istration at their disposal. This may
contribute to a placebo effect. Further
work needs to be done with this novel
but, as yet, less established tool of
providing analgesia to determine opti-
mum dose without increasing side-
effects.
We experienced a case of cerebral hyp-
operfusion during systemic hypotension,
which was detected by continuous
monitoring of regional cerebral oxygen
saturation (rCsO2) by near-infrared
spectroscopy in a patient whose collateral
circulation through the Circle of Willis
had been determined by a pre-operative
balloon occlusion test.
A 71-year-old woman with cancer of
the oropharynx was admitted to our
hospital. She had a history of varicose
veins in the lower extremities. Prior to
the scheduled operation, irradiation to
her tumour and chemotherapy were
performed effectively. Three months
later the patient underwent tumour
resection, radical neck dissection, recon-
struction using a forearm musclocutane-
ous flap and tracheostomy. During the
postoperative period, the patient suffered
from a refractory wound infection and
graft thrombosis. Ten days after the last
operation, when the dressing was being
changed, blood was found to be oozing
from both the neck and the oral cavity. A
cerebral angiogram was performed in
order to determine the most appropriate
therapeutic strategy. The patency of the
Circle of Willis was confirmed by cer-
ebral angiography, and left common
carotid artery (CCA) occlusion for
20 min induced no neurological symp-
Cerebral angiography with unilateral
carotid artery balloon occlusion is a
popular method of testing the function
of the circle of Willis [4]. In our patient,
the test suggested normal collateral
circulatory function, yet during the
CCA ligation, transcranial cerebral
oximeter (INVOS 3100 A) indicated a
P. Wong
decrease in rCsO2 during systolic hypo-
F. D. Chadwick
tension suggesting cerebral hypoper-
fusion from an insufficient collateral
circulation. When severe systemic
hypotension is present, cerebral blood
flow decreases and cerebral hypoper-
fusion may occur even if the Circle of
Willis is intact. A decrease in rCsO2
correlates well with cerebral blood
flow [5].
J. Karovits
Guy’s Hospital,
London SE1 9RT, UK
E-mail: docpatwong@yahoo.com
References
1
Striebel HW, Pommerening J, Rieger
A. Intranasal fentanyl titration for
postoperative pain management in an
Ó 2003 Blackwell Publishing Ltd
819