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International Journal of Obstetric Anesthesia (2006) 15, 68–70 Ó 2005 Elsevier Ltd. All rights reserved.
A case of unilateral Horner’s syndrome after combined spinal epidural anesthesia with ropivacaine 10 mg/mL P. D. Theodosiadis, V. O. Grosomanidis, F. V. Gkoutzioulis, J. M. TzafettasObstetric Department, Interbalkan Medical Center, Thessaloniki, Greece SUMMARY. We report a case of transient unilateral Horner’s syndrome during the setting of combined spinalepidural anesthesia for elective cesarean section using ropivacaine 10 mg/mL. The pathophysiology of Horner’ssyndrome and the possible mechanisms in relation to combined spinal epidural anesthesia are also presented.
Ó 2005 Elsevier Ltd. All rights reserved.
Keywords: Horner’s syndrome; Pregnancy; Combined spinal epidural anesthesia infused, then, with the patient in the sitting position, a Horner’s syndrome is a triad of miosis, ptosis and combined spinal-epidural was sited at L3/4 lumbar inter- enophthalmos commonly associated with vasodilatation space using the needle through needle technique. The (facial flashing), anhydrosis and nasal stuffiness.
epidural space was located with a 17-gauge Tuohy nee- Horner’s syndrome has been reported following several dle using loss of resistance to saline and 1% ropivacaine regional anaesthetic techniques, including brachial 2 mL was given intrathecally via a 25-gauge Whitacre plexus blockand thoracic and lumbar epidural anesthe- spinal needle, followed by insertion of an epidural cath- siaSeveral cases have been reported in obstetric pa- eter. The patient was turned on to the left lateral posi- tients using bupivacaine and ropivacaine epidural tion. There were no episodes of hypotension. The level but there are no reports of Horner’s syndrome following of the block to cold sensation was ascertained at T4 spinal injection of a local anesthetic in the obstetric set- bilaterally just before the cesarean section. A healthy ting. Moreover we could not find any data in the avail- baby was born with 1- and 5-min Apgar scores 9 and able literature (MEDLINE) regarding the occurrence of Horner’s syndrome after subarachnoid injection of ropi- Ten minutes after the delivery, and 20 min after the spinal injection of ropivacaine, the patient complained We report a case in which a patient developed of heaviness of the left eye lid, swelling of the left eye Horner’s syndrome after the subarachnoid injection of and loss of strength of the left arm. Examination re- ropivacaine as a single agent for cesarean section.
vealed left miosis, ptosis and conjunctival hyperemia.
A diagnosis of left Horner’s syndrome was assumed.
The sensory block to cold was now T3-4 on the left side and at T4-5 on the right. A consultant neurologist wascalled and confirmed the initial diagnosis.
A 27-year-old, 75 kg, 168-cm primigravida was sched- The patient was transferred for CT scan and intracra- uled for cesarean section because of cephalopelvic dis- nial pathology was excluded, as there were no abnormalfindings. She was then transferred to the recovery roomfor closer observation. As the block started to subside the patient noticed an improvement of her symptoms.
Correspondence to: Dr. Panayiotis Theodosiadis, Consultant Once the block had completely receded, about 4-6 h Anesthetist, Anesthesia Department, 424 Military Hospital, later, there were no neurological symptoms. Subsequent Thessaloniki 54638, Greece, Tel.: +0030-6944763219; analgesia was provided using intramuscular morphine Horner’s syndrome after CSE ropivacaine for cesarean section 69 (1000-1500 mL) before the subarachnoid injection,which is critical to prevent the disastrous effect of hypo- To date there have been no reports of Horner’s syn- tension due to high sympathetic blockade.
drome in association with spinal anesthesia in obstetric The Horner’s syndrome in our case was unilateral, practice. In contrast, Horner’s syndrome is often re- probably because of the left lateral position (ropivacaine ported following epidural blockade, and the incidence is slightly hypobaric with the baricity of 0.9998 at has been found to be 1.33% associated with epidural 37 °C) and this is in agreement with previous reports analgesia for labor and 4% with epidural anesthesia of unilateral Horner’s syndrome associated with labor epidurals.For the same reason, the injection of ropiva- In our case, Horner’s syndrome manifested with a caine may result in a higher spread when the patient is sensory analgesia to the T3-4 level but it appears that kept in the sitting position for at least 2 min after the sympathetic blockade rose to a higher segmental level.
injection, as it has been demonstrated for bupivacaine.
The sympathetic nerve supply for the region arises from Thus, both ropivacaine and plain bupivacaine may be the intermediolateral grey column of C6 through T1.
unreliable for spinal anesthesia if the hyperbaric solution Ray et al.found a substantial individual variability is not used, as they occasionally produce high spinal in the innervation of the dilating fibers of the iris. The Therefore, as the optimal dosage of ropiva- sympathetic innervation controlling of the dilator pupil- caine is unknown, a hyperbaric solution for spinal anes- lae and opening of the eye was found to travel through thesia, especially for cesarean delivery, is considered one or more spinal roots between the levels of C8 and T4. They also showed that stimulation of the anterior Associated symptoms and signs are usually benign spinal roots between T1 and T4 induced dilation of the and resolve spontaneously. They are most commonly re- homolateral pupil. These fibers, after passing through lated to the Horner’s syndrome itself, e.g. nasal stuffi- the white rami communicantes, continue to the cervical ness, blurred vision, strange feeling over the affected sympathetic chain and ascend through the stellate and eye or hemiface. Patients are more likely to complain middle cervical ganglia to terminate in the superior cer- of respiratory discomfort because of nasal stuffiness vical ganglion. Unmyelinated fibers leave this ganglion than because of diminished chest wall motion.
and form the internal carotid plexus, which further di- Although in this case Horner’s syndrome was tran- vides, giving rise to the cavernous plexus. Fibers from sient, secondary to spinal cephalad spread of local anes- this plexus enter the orbit and send branches to the supe- thetic (ropivacaine), some cases may result from rior rectus and the levator palpebrae superioris muscles.
intracranial pathology and other causes of Horner’s syn- Some fibers innervate the dilator pupillae through the The purpose of this report is to review the theories, Paralysis of these various sympathetic pathways to explain the development of this complication of causes unopposed parasympathetic tone and results in spinal anesthesia and to heighten awareness of this be- miosis, ptosis and enopthalmos. The occurrence of nign condition among labor suite personnel. Last but Horner’s syndrome in the absence of sensory blockade not least, the symptomatic patient and anxious family may be explained by the high sensitivity of sympathetic members may need appropriate reassurance when a nerve fibers to local anestheticsand the fact that the diagnosis of Horner’s syndrome is made in the obstetric sympathetic blockade appears to be more cephalad than the sensory. In addition, distension of the epidural veinsduring pregnancy, which reduces the volume of the epi-dural space and Cerebrospinal Fluid (CSF), will favor cranial spread of local anesthetics.
It is known that sympathetic responses during spinal 1. Lennon R L, Gammel S. Horner’s syndrome associated with block can be depressed at levels well above those of sen- brachial plexus anesthesia using an axillary catheter. Anesth Analg1992; 74: 311.
sory block (two to six spinal segments higher)The 2. Nesmith R L, Herring S H, Marks M W, Speight K L, Efird R C, preganglionic B sympathetic fibres are anatomically Rauck R L. Early experience with high thoracic epidural available to spinal blockade and, according to Heavner anesthesia in outpatient submuscular breast augmentation. AnnPlast Surg 1990; 24: 299–302.
and de Jong, are more easily blocked than other types 3. Biousse V, Guevara R A, Newman N J. Transient Horner’s of fibers,although Bengtsson et al. report that B fibers syndrome after lumbar epidural anesthesia. Neurology 1998; 51: appear to be relatively resistant to spinal blockade.
4. Hogagaro J, Gjurhuus H. Two cases of reiterated Horner’s Patients with extensive sympathetic blockade would syndrome after lumbar epidural block. Acta Anaesthesiologica be expected to have pronounced hypotension which is absent in most of the patients reported.A possible 5. Chandrasekhar S, Peterfreund R A. Horner’s syndrome following very low concentration bupivacaine infusion for labor epidural explanation could be the adequate fluid administration analgesia. J Clin Anesth 2003; 15: 217–219.
70 International Journal of Obstetric Anesthesia 6. Zahn P K, Van Aken H K, Marcus A E. Horner’s syndrome 12. Gautier P E, De Kock M, Van Steenberge A, et al.
following epidural anesthesia with ropivacaine for cesarean Intrathecal ropivacaine for ambulatory surgery: a delivery. Reg Anesth Pain Med 2002; 27: 445–446.
comparison between intrathecal bupivacaine and intrathecal 7. Clayton K C. The incidence of Horner’s syndrome during lumbar ropivacaine for knee arthroscopy. Anesthesiology 1999; 91: extradural for elective Caesarean section and provision of analgesia during labour. Anaesthesia 1983; 38: 583–585.
13. Russell I F. Spinal anaesthesia for Caesarean section: the use of 8. Ray B S, Hinsley J C, Geohegan W. Preservations of the 0.5% bupivacaine. Br J Anaesth 1983; 55: 309–314.
distribution of the sympathetic nerves to the pupil and upper 14. Russell I F. Inadvertent total spinal for Cesarean section.
extremity as determined by stimulation of the anterior roots in 15. Logan M R, McClure J H, Wildsmith J A. Plain bupivacaine: an 9. Heavner J, De Jong R. Lidocaine blocking concentrations for unpredictable spinal anaesthetic agent. Br J Anaesth 1986; 58: B- and C-nerve fibers. Anesthesiology 1974; 40: 228–233.
10. Bengtsson M, Lofstrom J, Malmquist L. Skin conductance 16. Chung C J, Choi S R, Yeo K H, Park H S, Lee S I, Chin Y J.
responses during spinal analgesia. Acta Anaesthesiol Scand 1985; Hyperbaric spinal ropivacaine for cesarean delivery: a comparison to hyperbaric bupivacaine. Anesth Analg 2001; 93: 11. Holzman R. Unilateral Horner’s syndrome and brachial plexus anesthesia during lumbar epidural blockade. J Clin Anesth 2002; 17. Merrison A, Lhatoo S. Horner’s syndrome postpartum. BJOG



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