Hybrid method with explorative laparoscopy and anterior open approach for re-recurrent inguinal hernia

Abstract

The new guidelines of the HerniaSurge group recommend that only an expert hernia surgeon should repair a re-recurrent inguinal hernia. We report the efficacy of the hybrid method with explorative laparoscopy and anterior open approach for re-recurrent inguinal hernia repair. A 61-year-old man underwent anterior open preperitoneal mesh repair for right inguinal direct hernia and laparoscopic transabdominal preperitoneal repair for recurrence. Two years after the second surgery, re-recurrent inguinal hernia was confirmed. We carried out explorative laparoscopy for the re-recurrent inguinal hernia, which revealed a re-recurrent hernia orifice. We performed the anterior open approach while observing from the abdominal cavity. Explorative laparoscopy can help in accurately determining the orifice of the re-recurrent inguinal hernia. Based on that information, the hernia sac can be reached through the shortest route using the anterior open approach.

https://ift.tt/2qLIIdD

Right external iliac artery thrombus following the use of resuscitative endovascular balloon occlusion of the aorta for placenta accreta

Abstract

A 33-year-old female, 32 weeks and 1 day gestation, with known placenta accreta who presented to the emergency department with 2 h of severe abdominal pain, nausea and vomiting. She became hypotensive and underwent emergency cesarean section. Emergency general surgery was consulted for placement of a resuscitative endovascular balloon for aortic occlusion (REBOA). After successful delivery, the balloon was inflated in zone 3 and systolic blood pressure rose from 70 to 170 mmHg. The patient underwent hysterectomy for ongoing hemorrhage. The patient was taken to the surgical intensive care unit. The patient was noted to have pulses following removal of the sheath. Arterial brachial indices and arterial duplex was performed 48 h after sheath removal. The patient was found to have complete occlusion of the right external iliac artery. Vascular surgery was consulted and cut-down performed with thrombus removal via fogarty catheter. The patient was discharged 2 days later without further complication.

https://ift.tt/2FlevfU

Additional unloading of the left ventricle using the Impella LP 2.5 during extracorporeal life support in cases of pulmonary congestion

Abstract

Extracorporeal life support (ECLS) is used for the treatment of severe cardiogenic shock. However, pulmonary congestion can progress to a severe problem with ECLS therapy. We report our experience with the Impella system for severe pulmonary congestion with ECLS therapy. We used the Impella system for two patients, which led to successful unloading of the left ventricle. Impella implantation during ECLS support appears to be a promising concept. However, more evidence is required for further evaluation.

https://ift.tt/2qLIDXn

Necrotizing fasciitis caused by Kocuria rosea in an immunocompromised patient

Abstract

This case report describes an immunocompromised patient with a skin boil that progressed to necrotizing fasciitis. The aim of this brief report is to raise awareness regarding necrotizing soft tissue infections caused by an unusual organism, Kocuria rosea, a typically non-pathogenic organism, and outline the course of treatment currently considered to be the standard of care.

https://ift.tt/2Fw6Ds7

Colonic perforation due to amebiasis, a rare and lethal complication

Abstract

Amebiasis is still a major healthcare concern, especially in developing countries like Ecuador. The lack of sanitary control and hygiene measures make parasites infections still a burden for patients and physicians. Despite infections due to this parasites are usually mild, severe infections and fatal outcomes although rare still occur. Bowel perforation is a rare complication of amebiasis, and unfortunately, it continues to be almost fatal. We present a case of an Ecuadorian patient who presented to the emergency room with an acute abdomen, despite adequate surgery and critical care, the patient regrettably died. Bowel perforation due to Entamoeba histolytica was the final diagnosis.

https://ift.tt/2qRdmmh

Two cases of intestinal injuries due to seat belt without seat belt sign

Abstract

Although seat belts save lives after motor vehicle accidents, they may cause different types of injuries such as abdominal wall, intra-abdominal, neck and spine or vascular injuries. Seat belt sign indicates the severity of injuries, and usually the risk of intra-abdominal injuries is high when the seat belt sign exists. Here, we present two cases of intra-abdominal injuries caused by seat belts without seat belt sign.

https://ift.tt/2FhyGew

Compound volvulus: a case report and literature review

Abstract

Compound volvulus is an uncommon cause of acute abdomen and involves the twisting of the loops of ileum around the base of the sigmoid or vice versa. It is a surgical emergency that is often missed pre-operatively. We are reporting this case and reviewing the relevant literature to increase the awareness of this condition. A 37-year-old female presented at the Emergency Unit of our hospital with features thought to be acute peritonitis secondary to typhoid perforation and a differential of rupture appendix. She had laparotomy with the finding of a gangrenous twisted terminal ileum around the base of the sigmoid for which a right hemicolectomy and sigmoidopexy were done. Compound volvulus, though rare, can still be encountered in our environment. Prompt identification, adequate resuscitation and expedient intervention will reduce morbidity and mortality.

https://ift.tt/2qRdhyZ

A nutrition problem solved by a two-step endoscopic removal of a non-adjustable gastric band

Abstract

Bariatric surgery is an effective approach for weight loss and short-term improvement in metabolic disorders. Stenosis is a common complication of gastric banding. Balloon dilatation or gastrotomy has been employed in this setting. Few studies have indicated endoscopic removal of the band a feasible procedure. We present a 60-year-old female who underwent gastric banding in 1985 and suffered from late stenosis and malnutrition. Endoscopy revealed a severe stenosis. A two-step procedure was performed. Initially a coated stent was placed into the stenosis to achieve pressure necrosis. Two weeks later, the stent was removed and the band was removed endoscopically. The procedure was performed without any complications. The patient was discharged the next day. A follow-up after 2 months revealed no problems with stenosis or malnutrition. The procedure was a safe, efficient and convenient way of handling late stenosis after gastric banding.

https://ift.tt/2FhyCvi

Elective cholecystectomy as a rare presentation of metastatic breast cancer

Abstract

Cholecystectomy leads, occasionally, to the diagnosis of subclinical primary carcinomas and rarely metastatic tumors. The authors report the diagnosis of gallbladder metastasis after an elective cholecystectomy for symptomatic cholelithiasis. Histological examination disclosed a metastasis from a lobular breast carcinoma. Authors found no more than 25 case reports of breast cancer metastasis in English literature. Of those, only one reports first diagnosis after elective cholecystectomy with no radiological or macroscopic signs of malignancy. Rare clinical presentations, as in this case, should always be kept in mind specially in high volume centers. These rare presentations lack good quality evidence and challenge the best standard treatment regimen available. Multidisciplinary assessment is the key to maximize the risk/benefit of different treatment modalities. In this case report, although curative surgery was attempted, progression disease was typical of an advance staged disease.

https://ift.tt/2qIfxbH

Objective demonstration of improvement of neurogenic bowel dysfunction in a case of spinal cord injury following stem cell therapy

Abstract

Constipation in spinal cord injury patients is a frequent complication that leads to a reduction of quality of life, extensive psychological and economic strain on patients and healthcare systems. We report a 58-year-old man with an incomplete SCI secondary to L1 vertebral fracture, presented gait disorder with neurogenic bowel and bladder dysfunction. He received 300 million autologous mesenchymal stromal cells (MSC) in the subarachnoid space by lumbar puncture. After the third administration of MSC the patient had an important improvement in almost every functional scale of spinal cord injury, especially in the Krogh's Neurogenic Bowel Dysfunction scale. Our present observation supports recent clinical findings about the benefit of autologous stem cell therapy for the improvement of bowel dysfunction in patients suffering spinal cord injury.

https://ift.tt/2FhypZ2

Hemorrhagic necrosis of small bowel following small bowel obstruction as a late complication of sex reassignment surgery—a gap in transgender care

Abstract

For decades, Thailand has been at the forefront of sex reassignment surgeries. The neovagina created by recto-sigmoid vaginoplasty is much more complex procedure when compared with penile skin version technique, but yielded more satisfactory functional outcomes. We reported an unusual case of life-threatening small bowel obstruction following previously successful recto-sigmoid vaginoplasty in a transgender woman. Transgender individuals have unique healthcare needs. However, various gaps still exist to provide multi-disciplinary care for these patients. The rate of adhesive small bowel obstruction is highest in the early period of any intra-abdominal post-operative surgeries, but the risk remains life-long. Transgender women receiving complicated vaginoplasty should be instructed to continue long-term follow-up to ensure early detection and management of post-operative complications.

https://ift.tt/2qJHEaw

Synchronous volvulus of the sigmoid and transverse colon in a 26-year-old male

Abstract

We present a 26-year-old male patient who presented with complete bowel obstruction and peritonitis. His abdominal X-rays showed grossly distended large bowels with air–fluid levels. A differential diagnosis of sigmoid volvulus was entertained and the patient was taken for an exploratory laparotomy. Intraoperatively, we found a sigmoid volvulus and a concurrent transverse colon volvulus. A subtotal colectomy and colostomy was performed. The histopathology results showed mucosal and submucosal congestion, chronic inflammation, and no malignancy or dysplasia. Synchronous volvulus of the sigmoid and transverse colon is an extremely rare. Management includes endoscopic derotation and decompression followed by semi-elective surgery in non-complicated cases. When endoscopic decompression has failed or there is suspicion of necrosis or perforation, surgery is mandatory.

https://ift.tt/2FiG3lZ

Large intra-abdominal desmoid tumour posing diagnostic and therapeutic challenges, a case report

Abstract

We present the case of a 46-year-old gentleman originally from China who presented to the acute surgical assessment unit complaining of upper abdominal discomfort, dyspepsia and early satiety ongoing for the previous 6 months. On exam he had a palpable mass in the left upper quadrant. He underwent an esophagogastroduodenoscopy which was normal and later received a CT abdomen which identified a well-circumscribed soft tissue mass in the mesenteric fat and lying adjacent to the transverse colon with no obvious cleavage plane between them. Colonoscopy was then performed which was normal. After discussion at MDT he was taken for laparotomy. At laparotomy the mass was found to be adherent to major vessels, small bowel and large bowel necessitating an extended right hemicolectomy and small bowel resection. The mass itself could not be completely excised. Histology from the resected specimen confirmed desmoid tumour.

https://ift.tt/2qGgzos

Both Bupivacaine and Levobupivacaine inhibit colon cancer cell growth but not melanoma cells in vitro

Abstract

Background

Retrospective studies indicate that the use of regional anaesthesia causes a reduction in cancer recurrence after oncological surgery, which could be due to anaesthetic's negating effect on immunosuppression related to the surgical stress response. Local anaesthetics may also exert direct suppressive effects on malignant cells, an area where further investigation is urgently needed.

Methods

Human colon cancer cells and human melanoma cells were cultured and then treated with 1 mM bupivacaine or levobupivacaine for up to 24 or 48 h. Their migratory ability was measured by scratch assay, proliferation determined with Ki67 immunofluorescence staining, and apoptosis accessed with annexin V and PI staining on flow cytometry. The effects of bupivacaine and levobupivacaine on cellular signaling and molecular response, specifically, on endoplasmic reticulum stress (ERS), were studied with immunostaining and western blot.

Results

In colon cancer cells, treatment with bupivacaine and levobupivacaine significantly inhibited cell migration (**p < 0.01, ***p < 0.001; n = 4) and proliferation (**p < 0.01; n = 4), while increasing the expression of CHOP (***p < 0.001; n = 4) and decreased the expression of Grp78 (*p < 0.05; n = 4). These effects were not mirrored by melanoma cells, such that no significant increase in apoptosis was seen in either melanoma cell lines following treatment.

Conclusion

These in vitro data suggested that both bupivacaine and levobupivacaine suppress colorectal adenocarcinoma cell proliferation and migration, which are concurrent with increased endoplasmic reticulum stress. Conversely, melanoma cells are more resilient to these two commonly used local anaesthetics. Further in vivo studies or clinical trials are needed.

https://ift.tt/2QJ2br6

Peak airway pressure is lower during pressure-controlled than during manual facemask ventilation for induction of anesthesia in pediatric patients—a randomized, clinical crossover trial

Abstract

Purpose

Facemask ventilation during the induction of general anesthesia in paediatric patients remains a challenge as it may result in hypoxic conditions and gastric insufflation with subsequent regurgitation and aspiration. So far, it is unclear if pressure-controlled or manual facemask ventilation is preferable in children. We hypothesized that pressure-controlled ventilation in apnoeic children results in lower peak airway pressure and flow rates compared to manual ventilation at comparable respiratory rates and tidal volumes.

Methods

Sixty-two lung-healthy children undergoing scheduled ear-nose-throat surgery were included in the study. After the induction of anesthesia, the patient's lungs were consecutively ventilated via a facemask in either manual or pressure-controlled mode, in randomized order. The primary outcome measure was peak airway pressure. Secondary outcome measures included positive end-expiratory pressure, airway compliance, tidal volume and airway flow.

Results

Data of 52 patients could be analyzed. Pressure-controlled ventilation resulted in a lower mean and peak inspiratory pressure (both p < 0.001), airway pressure amplitude (p = 0.01) and inspiratory peak flow rate (p = 0.005) compared to manual ventilation. The ratio of inspiration to expiration time was lower in pressure-controlled ventilation compared to manual ventilation (p < 0.001).

Conclusion

Pressure-controlled facemask ventilation during induction of anesthesia in pediatric patients results in lower airway pressure, and lower flow rates compared to manual ventilation, at comparable tidal and minute volumes.

https://ift.tt/2qJFeIW

Bilateral central retinal artery occlusion from catastrophic antiphospholipid syndrome

A 23-year-old woman with history of systemic lupus erythematous presented with dizziness and headache and was admitted for the stroke workup. During her stay, she had sudden painless loss of vision in her right eye consistent with central retinal artery occlusion (CRAO). Ocular massage and paracentesis were attempted without success to resume the flow. She was started on oral high-dose steroids (1 mg/kg) for lupus flare and therapeutic anticoagulation for antiphospholipid syndrome (positive for anticardiolipin and beta-2 microglobulin antibodies). On day 4, she started having painful bluish discoloration of her left index finger and right fifth toe, and on day 5 she had acute onset of left blurry vision with findings consistent with CRAO. She fulfilled the criteria of catastrophic antiphospholipid syndrome and was started on intravenous pulse steroids, plasmapheresis and higher international normalised ratio goal of 3–3.5 with improvement in her left eye vision from 20/200 to 20/20 on near card test by the end of treatment.

https://ift.tt/2PUq5CH

Renal pseudomass: be aware of splenorenal fusion

Splenosis is the heterotopic implantation of splenic tissue that usually occurs in a previous major abdominal trauma or splenectomy setting. However, splenorenal fusion is an uncommon entity, categorised as a developmental anomaly. There have been several confirmed cases in the literature. Despite some helpful imaging features, it can be easily misdiagnosed as a neoplastic renal mass, resulting in unnecessary nephrectomy. Here we presented a case of splenorenal fusion in an elderly female patient, which was initially misdiagnosed as renal cell carcinoma in sonography. More specific imaging modalities and biopsy are helpful in suggesting the correct diagnosis.

https://ift.tt/2DeOE6q

Anti-HMGCR antibody-associated necrotising myopathy and its association with statin use

A 66-year-old man presented with chest pain and a 1-year history of generalised weakness, accompanied with generalised aches and pains. Symptoms worsened when he was initiated on statins. Investigations yielded high creatine kinase, high HMG-coenzymeA reductase (HMGCR) antibody titre, myopathic features on electromyography and muscle biopsy, and muscle atrophy on MRI. These results were in keeping with anti-HMGCR antibody myopathy. The patient responded well to immunosuppressive therapy.

https://ift.tt/2Q19OvX

Cerebral tuberculomas in a 6-year-old girl causing central diabetes insipidus

A 6-year-old girl presented acutely with worsening frontal headaches. She had a 3-month history of lethargy, reduced appetite, weight loss, cough and intermittent fevers. A chest X-ray showed a left upper lobe consolidation, and a CT head showed multiple enhancing lesions with significant surrounding oedema in both cerebral hemispheres. Due to the strong suspicion of tuberculosis (TB), she was admitted and treated with anti-TB therapy and steroids. Following this, pulmonary infection with Mycobacterium tuberculosis was confirmed by a positive PCR from induced sputum. Cerebral spinal fluid (CSF) analysis was normal and tested negative for M. tuberculosis on PCR. During her first week of treatment, she developed polyuria, nocturia and polydipsia and was diagnosed with central diabetes insipidus. She was started on desmopressin which rapidly improved her symptoms, and she was continued on desmopressin for 3 months. Currently, she remains well and has shown a good response to TB treatment.

https://ift.tt/2DeOwns

Clinical and radiological findings in a severe case of cleidocranial dysplasia

Cleidocranial dysplasia (CCD) is a rare congenital autosomal dominant condition, causing hypoplasia of the clavicle, abnormal formation of teeth, skeletal and craniofacial bones. CCD is caused by the mutation of RUNX2/CBFA1 present in the short arm of chromosome 6 at position 21.1, a transcription factor essential for the formation of teeth, cartilage and bone. Patients with CCD show the classical features of excessive mobility of the shoulder bone, lack of resorption of the deciduous teeth, failure to erupt permanent teeth, multiple impacted and supernumerary teeth, and open fontanelle and sutures of the skull. In this article we report a case of CCD in a 16-year-old male patient, with an aim to highlight the clinical, radiological and recommended treatment guidelines.

https://ift.tt/2PUpXmH

Secretory cervical schwannoma: first of its kind

Schwannomas arising from cervical sympathetic chain are rare benign neoplasms which are slow growing, usually asymptomatic, biochemically non-secretory and functionally inactive tumours. We present a case of secretory schwannoma arising from the cervical sympathetic chain, causing hypertension and associated with raised urinary catecholamine degradation by-products. Transcervical excision of the tumour was followed by normalisation of blood pressure and urinary vanillylmandelic acid levels and pathologically the tumour was proved to be a schwannoma.

https://ift.tt/2Dj591D

A Case of Upper Limb Osteomyelitis and Septic Arthritis Presenting as Pseudoparalysis in a Two-Week-Old

Pseudoparalysis presenting in infants is a rare manifestation, where infection and trauma are the principle differentials. We present a case of a two-week-old baby boy with pseudoparalysis who was initially diagnosed as Erb's palsy when presented in the emergency department and later re-presented with signs of sepsis. A later diagnosis of osteomyelitis of the humerus and septic arthritis of the shoulder was made. Despite antibiotic therapy and surgical drainage, the proximal epiphysis of his humerus remains abnormal; however, he has no apparent functional deficit of his right arm at four-year follow-up.

https://ift.tt/2qJaQ1c

Invasive Respiratory or Vasopressor Support and/or Death as a Proposed Composite Outcome Measure for Perioperative Care Research

BACKGROUND: There is a need for a clinically relevant and feasible outcome measure to facilitate clinical studies in perioperative care medicine. This large-scale retrospective cohort study proposed a novel composite outcome measure comprising invasive respiratory or vasopressor support (IRVS) and death. We described the prevalence of IRVS in patients undergoing major abdominal surgery and assessed the validity of combining IRVS and death to form a composite outcome measure. METHODS: We retrospectively collected perioperative data for 2776 patients undergoing major abdominal surgery (liver, colorectal, gastric, pancreatic, or esophageal resection) at Kyoto University Hospital. We defined IRVS as requirement for mechanical ventilation for ≥24 hours postoperatively, postoperative reintubation, or postoperative vasopressor administration. We evaluated the prevalence of IRVS within 30 postoperative days and examined the association between IRVS and subsequent clinical outcomes. The primary outcome of interest was long-term survival. Multivariable Cox proportional regression analysis was performed to adjust for the baseline patient and operative characteristics. The secondary outcomes were length of hospital stay and hospital mortality. RESULTS: In total, 85 patients (3.1%) received IRVS within 30 postoperative days, 15 of whom died by day 30. Patients with IRVS had a lower long-term survival rate (1- and 3-year survival probabilities, 66.1% and 48.5% vs 95.2% and 84.0%, respectively; P

https://ift.tt/2Dkm18f

Side Effect Rates of Opioids in Equianalgesic Doses Via Intravenous Patient-Controlled Analgesia: A Systematic Review and Network Meta-analysis

BACKGROUND: Side effects of opioids used for the treatment of acute pain frequently limit their analgesic quality. Many studies have compared opioid side effects in patient-controlled analgesia (PCA), but it remains unclear whether there are specific side effect profiles that can be exploited when choosing an opioid for a patient. In this review, we wanted to determine the risk ratios (RRs) for the most common side effects when using different opioids for intravenous PCA in equianalgesic doses and rank the substances accordingly. METHODS: A search of MEDLINE, EMBASE, the Cochrane Library (CENTRAL), and Web of Science identified 63 randomized controlled trials comparing opioids under equianalgesic conditions. Inclusion criteria were comparable pain stimulus between groups, equal coanalgesic treatment, and comparable resulting pain scores. Quality of studies was assessed using the Cochrane risk of bias tool with 6 items. Frequentistic network meta-analysis was conducted with morphine as the comparator. This method not only summarizes all estimated effects from direct comparisons of different interventions but also allows for indirect comparisons between interventions that can be linked via the common comparator, in which case the indirect evidence can be used to enhance the precision of the direct comparisons. Primary end points of this study were RRs for nausea and vomiting, pruritus, and events of sedation, as well as mean differences for scores of sedation. Events of respiratory depression were counted. Secondary end point was patient satisfaction (mean difference). The study protocol was registered at PROSPERO (CRD42017062355). RESULTS: Sixteen opioid interventions were compared in the largest network (nausea and vomiting outcome) and 7 opioid interventions in the smallest network (sedation events outcome). Most interventions did not differ from morphine on the primary outcomes (side effects), with some exceptions. Buprenorphine had a significantly higher RR of nausea and vomiting, whereas fentanyl had a lower RR of nausea and vomiting. Nalbuphine, butorphanol, methadone, and pethidine/meperidine had a lower risk of pruritus. Respiratory depression was rare (22 of 2452 patients). Pethidine/meperidine, fentanyl, and oxymorphone caused significantly lower sedation scores. Tramadol caused significantly lower satisfaction scores, whereas oxycodone, alfentanil, remifentanil, fentanyl, and pethidine/meperidine caused significantly higher satisfaction scores. CONCLUSIONS: The opiate chosen for treatment most likely has little effect on the incidence of pruritus and nausea/vomiting, although considerable differences exist in terms of better and worse opioids in the presented rankings. Larger differences between drugs were observed with regard to sedation and patient satisfaction, and choosing the appropriate opioid may help to improve PCA in this regard. Accepted for publication September 25, 2018. Funding: This work was supported by the institutional funds from the Department of Anesthesiology and Intensive Care of the University Hospital Marburg. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (https://ift.tt/KegmMq). Study Registration: PROSPERO: CRD42017062355. Reprints will not be available from the authors. Address correspondence to Hanns-Christian Dinges, MD, Department of Anesthesia and Intensive Care, University Hospital Marburg, Baldingerstrasse, 35033 Marburg, Germany.Address e-mail to dingesh@staff.uni-marburg.de. © 2018 International Anesthesia Research Society

https://ift.tt/2PRDDPd

Anesthesiology: A Practical Approach

No abstract available

https://ift.tt/2Di1eBR

Analgesic Efficacy and Safety of Intravenous Meloxicam in Subjects With Moderate-to-Severe Pain After Open Abdominal Hysterectomy: A Phase 2 Randomized Clinical Trial

BACKGROUND: An intravenous (IV) formulation of meloxicam was developed for moderate-to-severe pain management. This study evaluated the safety and efficacy of meloxicam IV after open abdominal hysterectomy. Meloxicam IV is an investigational product not yet approved by the US Food and Drug Administration. METHODS: Women (N = 486) with moderate-to-severe pain after open abdominal hysterectomy were enrolled in this multicenter, randomized, double-blind, placebo- and active-controlled trial. Subjects were randomized to receive a single dose of meloxicam IV (5–60 mg), placebo, or morphine (0.15 mg/kg) in ≤6 hours after morphine dosing on postoperative day 1 and were evaluated for 24 hours. Rescue morphine (≈0.15 mg/kg IV) was available if needed for pain not relieved by the study medication. In an open-label extension (N = 295), meloxicam IV was administered once daily for the remaining hospital stay (or per the investigator's discretion). The coprimary efficacy end points were the summed pain intensity difference (SPID24) and total pain relief (TOTPAR24) from hour 0 to 24 hours after dosing. Effect size, the standardized difference between means reported in standard deviation (SD) units, was calculated to indicate the magnitude of the difference in the mean analgesic effect measured for different intervention groups. RESULTS: Subjects who received morphine or meloxicam IV had a median time to first perceptible pain relief within 6–8 minutes. Morphine and meloxicam IV 5–60 mg produced statistically significant differences than placebo in SPID24 and TOTPAR24. SPID24 (standard error [SE]) for meloxicam IV 5–60 mg ranged from −56276.8 (3926.46) to −33517.1 (3930.1; P

https://ift.tt/2PT7hDT

Essentials of Trauma Anesthesia, 2nd ed

No abstract available

https://ift.tt/2Dg566t

An Observational Study of Cerebral Blood Flow Velocity Evaluation in the Prone Position During Posterior Lumbar Surgery

BACKGROUND: Prone positioning (PP) is necessary for surgical access during posterior spine procedure. However, physiological changes occur in the PP. Typical findings are a decrease in arterial blood pressure and in cardiac output that could potentially lead to an alteration in cerebral perfusion. Therefore, we decided to study cerebral blood flow velocity (CBFV) with transcranial Doppler ultrasonography to evaluate the effect of the PP on cerebral hemodynamics. METHODS: Twenty-two patients undergoing spine surgery in the PP were studied. General anesthesia was induced using 250 μg of fentanyl, 2 mg/kg of propofol, and 0.1 mg/kg of vecuronium, and was maintained with 0.25%–0.5% isoflurane, 50% nitrous oxide in oxygen, continuous infusion of 100 μg/kg/min of propofol, 1.5 μg/kg/h of fentanyl, and 0.15 mg/kg/h of ketamine. Continuous invasive arterial blood pressure, heart rate, electrocardiogram, and end-tidal carbon dioxide were monitored. CBFV with transcranial Doppler in the middle cerebral artery was first measured with the patients under general anesthesia in the supine position. Patients were then placed in the PP and remained in this position throughout surgery. CBFV, end-tidal carbon dioxide, heart rate, and blood pressure were measured continuously for 75 minutes after initiation of PP. This coincided with surgical exposure and minimal blood loss. Data were analyzed every 15 minutes for statistical significant change over time. RESULTS: Mean arterial blood pressure decreased 15 minutes after the installation of the PP and onward, but this decrease was not statistically significant. CBFVsyst (the maximal CBFV during the systolic phase of a cardiac cycle) and CBFVmean (the time averaged value of the maximal velocity envelope over 1 cardiac cycle) did not vary at any time points. CBFVdiast (the CBFV just before the acceleration phase [systole] of the next waveform) was lower at T3 (30 minutes after PP) compared to T1 (value derived averaging the first measure in the PP with the ones at 5 and 10 minutes) (P = .01), and the pulsatility index was higher at T5 (60 minutes after PP) compared to T0 (baseline, patient supine under general anesthesia) (P = .04). Data were analyzed at specific time points (T0 and T1). This value was derived by computing an average of the CBFV values collected at the first measure in the PP and at 5 and 10 minutes thereafter: T2, 15 minutes after PP; T3, 30 minutes after PP; T4, 45 minutes after PP; T5, 60 minutes after PP; and T6, 75 minutes after PP. CONCLUSIONS: Our data on CBFV during PP for spine surgery demonstrate preservation of cerebral perfusion during stable systemic hemodynamic conditions. The present results do not allow us to determine whether the PP would be similarly tolerated with increasing length of surgery, variations in systemic hemodynamics, and in different patient populations. Accepted for publication September 19, 2018. Anna Maria Bombardieri, MD, PhD, is currently affiliated with the Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri. Funding: This study was supported by funds from the Department of Anesthesiology at the Hospital for Special Surgery, New York City, NY Conflicts of Interest: See Disclosures at the end of the article. Institutional review board: Edward Jones, MD, Chairman, Hospital for Special Surgery, 535 E 70th St. E-mail: JonesE@hss.edu. This article describes human research (institutional review board number 10092) from a cohort observational clinical study. The authors state that the report includes every item in the Strengthening the Reporting of Observational studies in Epidemiology checklist for cohort observational clinical studies. Funding: This study was supported by funds from the Department of Anesthesiology at the Hospital for Special Surgery, New York City, NY. This study was presented in part at the annual meeting of the American Society of Anesthesiologists, Chicago, IL, October 18, 2011. This study was conducted with written informed consent from the study subjects. Reprints will not be available from the authors. Address correspondence to Anna Maria Bombardieri, MD, PhD, Department of Anesthesiology, Washington University School of Medicine, 660 S. Euclid Ave, Box 8054, St Louis, MO 63110. Address e-mail to annamariabombardieri@wustl.edu. © 2018 International Anesthesia Research Society

https://ift.tt/2PS5pLp

Trends in Authorship in Anesthesiology Journals

Despite increasing representation in medicine, women continue to be a minority in academic practice and leadership, especially in male-dominated fields like anesthesiology. Differences in compensation and participation in leadership may represent barriers to career advancement for women in anesthesiology. Key factors for promotion in academic anesthesiology are research, funding, and publication. As such, designation as a first or senior author on a publication in a professional journal may act as currency for promotion. Here, we examine the prevalence of female first and senior authorship of original research articles published in Anesthesiology and Anesthesia& Analgesia during the years 2002, 2007, 2012, and 2017. Other manuscript characteristics assessed in relation to author gender included study type, subspecialty topic, and total number of authors. Of 2600 manuscripts studied, analysis of authorship by year demonstrated an increase in female first authorship, senior authorship, and editorial board membership by 10%, 9%, and 6%, respectively. Women made up a higher percentage of first authors on manuscripts with female senior authors. More nonexperimental studies had female senior authors than experimental studies. Female first authors had greater representation in the subspecialties of neuroanesthesia, obstetrical anesthesia, pain management, and pediatric anesthesia. Median number of authors was unrelated to senior author gender. This study shows increasing female first and senior authorship, as well as editorial board composition in 2 popular, high-impact anesthesiology journals. Recognizing gender-based trends in publications is important to develop strategies for the recruitment, retention, and advancement of women in anesthesiology. Accepted for publication October 18, 2018. Funding: None. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Joanna Miller, MD, Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, One Gustave Levy Pl, PO Box 1010, New York, NY 10029. Address e-mail to Joanna.miller@mountsinai.org. © 2018 International Anesthesia Research Society

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Distribution of Extreme Vital Signs and Complete Blood Count Values of Healthy Parturients: A Retrospective Database Analysis and Review of the Literature

BACKGROUND: The impact of physiological adjustments throughout pregnancy on maternal vital signs and laboratory values has yet to be fully defined. The present study was designed to determine the normal range of these parameters among healthy pregnant women during the peripartum period. METHODS: This is a retrospective analysis of data collected during real-time deliveries in a single medical center. Vital signs and laboratory results from the 24 hours preceding delivery room admission and up to 72 hours postpartum were collected. Only pregnant women at term (370/7 to 416/7 weeks' gestation) with a liveborn, singleton gestation, and no chronic disease or obstetric complication that could affect the physiological parameters under study were included. The mean, range, and standard deviations of the extremes of all parameters at 3 distinct time points (prelabor, intrapartum, and postpartum) were calculated. The 2.5 and 97.5 percentiles for each parameter were reported as the normal range. RESULTS: A total of 32,161 cases fulfilled inclusion criteria. The average gestational age at delivery was 393/7 weeks ± 8 days, and one-third of the cases were primiparous. During labor and after delivery, the upper limits of normal blood pressure values were 147/94 and 145/94 mm Hg, respectively. The lower limits were 83/43 and 83/42 mm Hg, respectively. Normal heart rates were 60–115 beats/min prelabor, 51–120 beats/min intrapartum, and 50–120 beats/min postpartum. Lowest normal temperatures ranged between 36.0°C and 36.3°C in the 3 study time points, and highest normal temperatures were 37.2°C prelabor and 37.6°C intra- and postpartum. The normal ranges of white blood cell counts were 6.1–16.8 prelabor, 6.5–22.5 intrapartum, and 6.4–23.9 K/µL postpartum. Normal low values of hemoglobin were 9.7, 8.7, and 7.1 g/dL and of platelets were 117, 113, and 105 K/µL, respectively. CONCLUSIONS: Our findings justify the practice of using ≥2 repeated measurements for diagnosing hypertensive disorders of pregnancy. Lower normal blood pressure limits may be below those defining hypotensive shock. Normal heart rates exceed the accepted definitions of both tachy- and bradycardia. Normal temperatures at all times have a more narrow range than previously thought, and the normal range of white blood cell count has outliers exceeding the current definitions of leukocytosis or leukopenia at all times. The normal lower range of hemoglobin was constantly below 10 g/dL, and normal platelet counts were considerably lower than those previously described. The vital signs and complete blood count values thus far considered normal for the peripartum period may require some adjustment. New definitions for hypotension, tachy- and bradycardia, fever, and leukocyte quantitative disorders should be considered. Accepted for publication September 18, 2018. Funding: None. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (https://ift.tt/KegmMq). Institutional review board at Helsinki Committee, Rabin Medical Center, Jabotinsky St 39, Petah Tikva, Israel provided approval: 0421-15-RMC, submitted July 2015, approved October 2015. E-mail: avitalbe1@clalit.org.il. Reprints will not be available from the authors. , Address correspondence to Roi Gat, MD, Helen Schneider's Hospital for Women, Rabin Medical Center, Ze'ev Jabotinsky Rd 39, Petah-Tikva 4941492, Israel. Address e-mail to Gatroimd@googlemail.com. © 2018 International Anesthesia Research Society

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Relationship Between Preoperative Antidepressant and Antianxiety Medications and Postoperative Hospital Length of Stay

BACKGROUND: Patients on antidepressant or antianxiety medications often have complex perioperative courses due to difficult pain management, altered coping mechanisms, or medication-related issues. This study examined the relationship between preoperative antidepressants and antianxiety medications on postoperative hospital length of stay while controlling for confounding variables. METHODS: From an administrative database of 48,435 adult patients who underwent noncardiac surgery from 2011 to 2014 at a single, large urban academic institution, multivariable zero-truncated negative binomial regression analyses controlling for age, sex, medical comorbidities, and surgical type were performed to assess whether preoperative exposure to antidepressant or antianxiety medication use was associated with postoperative hospital length of stay. RESULTS: There were 5111 (10.5%) patients on antidepressants and 4912 (10.1%) patients on antianxiety medications. The median length of stay was 3 days (interquartile range = 2–6). After controlling for confounding variables, preoperative antidepressant medication was associated with increased length of stay with an incidence rate ratio of 1.04 (99% confidence interval, 1.0–1.08, P

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Clockwise Versus Counterclockwise Rotation of Endotracheal Tube When Using Videolaryngoscopy in Children

No abstract available

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Intravascular Cooling Device Versus Esophageal Heat Exchanger for Mild Therapeutic Hypothermia in an Experimental Setting

BACKGROUND: Targeted temperature management is a standard therapy for unconscious survivors of cardiac arrest. To date, multiple cooling methods are available including invasive intravascular cooling devices (IVDs), which are widely used in the clinical setting. Recently, esophageal heat exchangers (EHEs) have been developed providing cooling via the esophagus that is located close to the aorta and inferior vena cava. The objective was to compare mean cooling rates, as well as differences, to target temperature during maintenance and the rewarming period of IVD and EHE. METHODS: The study was conducted in 16 female domestic pigs. After randomization to either IVD or EHE (n = 8/group), core body temperature was reduced to 33°C. After 24 hours of maintenance (33°C), animals were rewarmed using a target rate of 0.25°C/h for 10 hours. All cooling phases were steered by a closed-loop feedback system between the internal jugular vein and the chiller. After euthanasia, laryngeal and esophageal tissue was harvested for histopathological examination. RESULTS: Mean cooling rates (4.0°C/h ± 0.4°C/h for IVD and 2.4°C/h ± 0.3°C/h for EHE; P

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Smith’s Anesthesia for Infants and Children, 9th ed

No abstract available

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Noninvasive Continuous Blood Pressure Monitoring: Are the Intraoperative Episodes of Hypotension in Clear Sight?

No abstract available

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Acute Kidney Injury and Risk of Death After Elective Surgery: Prospective Analysis of Data From an International Cohort Study

BACKGROUND: Postoperative acute kidney injury (AKI) is associated with a high mortality rate. However, the relationship among AKI, its associations, and mortality is not well understood. METHODS: Planned analysis of data was collected during an international 7-day cohort study of adults undergoing elective in-patient surgery. AKI was defined using Kidney Disease Improving Global Outcomes criteria. Patients missing preoperative creatinine data were excluded. We used multivariable logistic regression to examine the relationships among preoperative creatinine-based estimated glomerular filtration rate (eGFR), postoperative AKI, and hospital mortality, accounting for the effects of age, major comorbid diseases, and nature and severity of surgical intervention on outcomes. We similarly modeled preoperative associations of AKI. Data are presented as n (%) or odds ratios (ORs) with 95% confidence intervals. RESULTS: A total of 36,357 patients were included, 743 (2.0%) of whom developed AKI with 73 (9.8%) deaths in hospital. AKI affected 73 of 196 (37.2%) of all patients who died. Mortality was strongly associated with the severity of AKI (stage 1: OR, 2.57 [1.3–5.0]; stage 2: OR, 8.6 [5.0–15.1]; stage 3: OR, 30.1 [18.5–49.0]). Low preoperative eGFR was strongly associated with AKI. However, in our model, lower eGFR was not associated with increasing mortality in patients who did not develop AKI. Conversely, in older patients, high preoperative eGFR (>90 mL·minute−1·1.73 m−2) was associated with an increasing risk of death, potentially reflecting poor muscle mass. CONCLUSIONS: The occurrence and severity of AKI are strongly associated with risk of death after surgery. However, the relationship between preoperative renal function as assessed by serum creatinine-based eGFR and risk of death dependent on patient age and whether AKI develops postoperatively. Accepted for publication October 3, 2018. Funding: This was an investigator-initiated study funded by Nestle Health Sciences through an unrestricted research grant, and by a National Institute for Health Research (United Kingdom) Professorship held by R.M.P. H.C. was part-supported for this research project by the John Snow Award jointly administered by the Royal College of Anaesthetics, the British Journal of Anaesthesia, and the National Institute of Academic Anaesthesia. This study was sponsored by Queen Mary University of London. Conflicts of Interest: See Disclosures at the end of the article. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (https://ift.tt/KegmMq). Members of International Surgical Outcomes Study (ISOS) group are listed in Supplemental Digital Content, https://ift.tt/2DgrGfj. International Surgical Outcomes Study investigators were entirely responsible for study design, conduct, and data analysis. The authors had full data access and were solely responsible for data interpretation, drafting, and critical revision of the manuscript, and the decision to submit for publication. Reprints will not be available from the authors. Address correspondence to John R. Prowle MD, Adult Critical Care Unit, Royal London Hospital, London, E1 1BB, United Kingdom. Address e-mail to j.prowle@qmul.ac.uk. © 2018 International Anesthesia Research Society

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Congenital intrahepatic portocaval shunts and hypoglycemia due to secondary hyperinsulinism: a case report and review of the literature

Congenital portosystemic shunts present with various associated complications, such as other congenital malformations, hyperammonemia, or hepatopulmonary syndrome. Few cases of associated hypoglycemia have bee...

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