Effect of remifentanil on postoperative nausea and vomiting: a randomized pilot study

Abstract

Opioid-related postoperative nausea and vomiting should not occur following remifentanil administration because of its relatively short time to elimination. However, studies have indicated that the incidence of postoperative nausea and vomiting associated with remifentanil is similar to that with other opioids. Hence, we aimed to determine whether intraoperative remifentanil itself is associated with postoperative nausea and vomiting when postoperative pain is managed without opioid use. In this prospective pilot study, 150 patients who underwent unilateral upper limb surgery under general anesthesia with brachial plexus block were included. Patients in the remifentanil and control groups received 0.5 µg/kg/min remifentanil and saline, respectively. Postoperative pain was managed using a brachial plexus block, non-steroidal anti-inflammatory drugs, and acetaminophen. The presence of postoperative nausea and vomiting within the first 24 h after anesthesia was assessed by an evaluator blinded to patient allocation. Eight patients were excluded from the final analysis, resulting in 72 and 70 patients in the remifentanil and control groups, respectively. Postoperative nausea and vomiting within 24 h after surgery occurred in 11 and 9 patients in the remifentanil and control groups, respectively. These data suggest that remifentanil use only minimally affects the incidence of postoperative nausea and vomiting under sevoflurane anesthesia.

UMIN Clinical Trials Registry identification number: UMIN000016110.

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Perforation of small intestine due to metastatic lung carcinoma

Description 

A 66-year-old woman with a history of 40 pack-year cigarette smoking and type II diabetes mellitus presented to the emergency department with unexplained weight loss and cough for a few weeks. These complaints constituted her first clinical manifestation. Physical examination was notable for diffuse abdominal tenderness. Chest and abdominal films (figure 1) revealed a prominent round opaque lesion in the right lung (arrow) and a large amount of free air under diaphragms with air-fluid levels.

Figure 1

Upright chest (left) and abdominal (right) films demonstrating round opaque lesion (arrow) and free air under diaphragms and levels of fluid in the stomach and intestine.

The patient underwent an urgent laparotomy for pneumoperitoneum. Perforation of the small intestine due to a malignant metastasis was detected. The patient underwent a wide resection of the small intestine with closed loop anastomosis. The biopsy specimen was consistent with...

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Posterior urethral valve presenting with impacted prostatic urethral calculus: a diagnostic challenge

Description 

A 5-year-old boy presented with complaints of difficulty in micturition for the last 3 days and acute urinary retention for 1 day. History revealed symptom of occasionally crying during voiding since birth for which no medical advice was taken in the past. There was no history of any lithuria, haematuria or recurrent episodes of fever. The general physical examination was unremarkable. The routine blood investigations and urine culture were also normal. Urine routine microscopy showed 4–5 pus cells/HPF. Ultrasonography of the abdomen revealed thickening of the bladder wall with normal upper tracts. Further evaluation with X-ray pelvis and voiding cystourethrogram (VCUG) showed a radiopaque shadow in the prostatic urethra along with dilated posterior urethra as shown in figure 1. The patient was subsequently taken for cystopanendoscopy which revealed posterior urethral valve type one along with a dilated posterior urethra as shown in figure 2....

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The rare and unusual presentation of a gastric perforation in the setting of a large diaphragmatic hernia: a case report and literature review

Abstract

Diaphragmatic hernias are either congenital or acquired defects in the diaphragm that permit passing of abdominal contents into the chest cavity. Individuals with large diaphragmatic hernias associated with a gastric perforation have rarely been reported in literature and can have serious mortality rates. Herein, we present a case of gastric perforation in the setting of a significant sized diaphragmatic hernia. The value of the current report compared to previously published cases is the sub-acute nature and lack of any indicative features on initial presentation which can lead to misdiagnosis and serious morbidity later in life.

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Intracranial bleeding (ICB) as a catastrophic complication of Streptococcus gordonii infective endocarditis (IE) in an immunocompetent patient

We present an interesting case of late-onset intracranial bleeding (ICB) as a complication of Streptococcus gordonii causing infective endocarditis. A previously healthy young woman was diagnosed with infective endocarditis. While she was already on treatment for 2 weeks, she had developed seizures with a localising neurological sign. An urgent non-contrasted CT brain showed massive left frontoparietal intraparenchymal bleeding. Although CT angiogram showed no evidence of active bleeding or contrast blush, massive ICB secondary to vascular complication of infective endocarditis was very likely. An urgent decompressive craniectomy with clot evacuation was done immediately to release the mass effect. She completed total 6 weeks of antibiotics and had postoperative uneventful hospital stay despite having a permanent global aphasia as a sequel of the ICB.

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Rare cause of gastric outlet obstruction: xanthogranulomatous cholecystitis

Description 

A 62-year-old Indian female patient presented with right upper quadrant pain and multiple episodes of vomiting for 10 days. She denied history of fever, jaundice, past anorexia/weight loss and previous surgeries. She was dehydrated, tachycardia (120/min) was present, and there was tenderness in the right upper quadrant. Routine investigations revealed presence of anaemia (haemoglobin 9.1 g/dL), raised total leucocyte counts (17 x10^9/L) and hypokalaemia (2.8 mEq/L). All other blood tests (liver function/kidney function/blood sugar and coagulation profile) were normal. Patient was stabilised with intravenous fluids, antibiotics and other supportive management. Imaging with ultrasound (USG) was suboptimal due to the massive intestinal gas and uncooperative nature of the patient. A collapsed gallbladder (GB) and a mass with a smooth curvilinear surface and posterior acoustic shadowing in the distal part of the duodenum were the only distinguishable findings. Due to repeated episodes of vomiting, the patient underwent an upper gastrointestinal endoscopy, which was...

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Tubercular septal abscess in a postoperative patient: a novel entity

Extrapulmonary tuberculosis is a rather uncommon and potentially challenging phenomenon. Such manifestation, particularly in the scenario of a late postoperative period, is extremely rare and requires a high index of suspicion, prompt diagnosis and appropriate treatment.

We present the case scenario of a patient with history of successfully treated pulmonary tuberculosis many years earlier, without any signs of recurrence, who developed primary nasal septal tuberculosis after undergoing septoplasty to correct his septal deviation. His postoperative course remained uneventful for 4 months. He then presented with a spontaneous nasal septal abscess, which proved to be tubercular in nature on investigations. Appropriate diagnosis was established, and the patient was treated successfully with antituberculous therapy.

Recurrent tuberculosis may present a diagnostic challenge for healthcare professionals. Only a high index of suspicion, modern diagnostic tools and institution of appropriate treatment including surgical intervention as required will ensure a promising outcome.

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