Devanand Mangar

Tourniquet at 50 mm Hg followed by intravenous lidocaine diminishes hand pain associated with propofol injection

&NA; We evaluated the efficacy of intravenous lidocaine, with and without a tourniquet, to decrease the intensity of pain during intravenous propofol injection in 82 patients undergoing general anesthesia. Patients in group A (n = 20) received propofol (2 mg/kg IV); patients in group B (n = 22) received 2% lidocaine (100 mg IV) followed 1 min later by propofol (2 mg/kg). Patients in group C (n = 21, saline placebo) and D (n = 19, 2% lidocaine) had an arm tourniquet inflated to 50 mm Hg applied for 1 min after gravity drainage of venous blood. The intensity of pain along the forearm was marked on a 0‐100‐mm visual analogue scale. Pain intensity was less in group B (21 ± 19 mm) than in group A (75 ± 28 mm; P < 0.05). Pain intensity was significantly less in group D (1 ± 2 mm) compared with group B (21 ± 19 mm; P < 0.001). We conclude that intravenous lidocaine before propofol injection attenuates the painful response; whereas, lidocaine administered after a tourniquet inflated to 50 mm Hg for 1 min virtually abolishes the pain associated with intravenous propofol.

Electrocautery-induced pacemaker malfunction during surgery

We report a case of electrocautery-induced pacemaker failure that resulted in asystole in a 15-year-old girl scheduled for cardiac surgery. Her pacemaker was converted to the asynchronous mode the night before surgery. Electromagnetic interference from the unipolar electrocautery caused a reducion in the battery voltage, which allowed the digital circuitry, but not the voltage control oscillator (VCO), to work properly. Eventually the battery current drain caused VCO “lock-out,” and pacemaker and battery failure. This report demonstrates that electrocautery-induced pacemaker failure can occur, even after conversion to asynchronous mode.RésuméNous rapportons le cas du mauvais fonctionnement d’un pacemaker causé par l’électrocautère et qui a mené à une asystolie chez une patiente de 15 ans qui devait subir une chirurgie cardiaque. Son pacemaker a été converti à un mode asynchrone la nuit avant la chirurgie. L’interférence électromagnétique de l’électrocautère unipolaire a causé une diminution du voltage de la pile. Ceci a permis au circuit digital, mais non à l’oscillateur de contrôle du voltage (VCO), de bien fonctionner. Eventuellement, la fuite de courant de la pile a causé une mise en veilleuse du VCO, et une panne du pacemaker et de la pile. Ce communiqué nous démontre qu une panne du pacemaker causée par l’électrocautère peut survenir, même après une conversion à un mode asynchrone.

Important surgical considerations in the management of renal cell carcinoma (RCC) with inferior vena cava (IVC) tumour thrombus.

Whats known on the subject? and What does the study add?

Morbidity associated with nonemergent hysterectomy for placenta accreta

OBJECTIVE The purpose of this study was to report the morbidity of nonemergent hysterectomy for suspected placenta accreta. STUDY DESIGN This was a retrospective study of all patients who underwent nonemergent hysterectomy for placenta accreta at Tampa General Hospital from June 1, 2003 to May 31, 2009. RESULTS Twenty-nine patients were identified. Diagnosis was suspected on ultrasound scanning in 26 women (6 women also underwent magnetic resonance imaging) and on direct vision at repeat cesarean section delivery in 3 women. All of the women were multiparous, and 18 women had undergone > or =2 cesarean section deliveries. Twenty-one women had a placenta previa, and 8 women had a low anterior placenta. Final pathologic findings revealed accreta (20 specimens), increta (6 women), and percreta (3 women). Mean total operative time was 216 minutes; blood loss was 4061 mL. Two women had ureteral transection (1 was bilateral); 3 women had cystotomy, and 3 women had partial cystectomy. Postoperative hemorrhage occurred in 5 women; 1 hemorrhage resolved after catheter embolization, and the other 4 hemorrhage required reoperation. CONCLUSION Nonemergent hysterectomy for placenta accreta is associated with significant morbidity in the forms of hemorrhage and urinary tract insult.

Hyperbaric oxygen therapy in femoral head necrosis.

We evaluated hyperbaric oxygen (HBO) therapy on a cohort of patients with femoral head necrosis (FHN). This double-blind, randomized, controlled, prospective study included 20 patients with unilateral FHN. All were Ficat stage II, treated with either compressed oxygen (HBO) or compressed air (HBA). Each patient received 30 treatments of HBO or HBA for 6 weeks. Range of motion, stabilometry, and pain were assessed at the beginning of the study and after 10, 20, and 30 treatments by a blinded physician. After the initial 6-week treatment, the blind was broken; and all HBA patients were offered HBO treatment. At this point, the study becomes observational. Pretreatment, 12-month. and 7 year-follow-up magnetic resonance images were obtained. Statistical comparisons were obtained with nonparametric Mann-Whitney U test. Significant pain improvement for HBO was demonstrated after 20 treatments. Range of motion improved significantly during HBO for all parameters between 20 and 30 treatments. All patients remain substantially pain-free 7 years later: none required hip arthroplasty. Substantial radiographic healing of the osteonecrosis was observed in 7 of 9 hips. Hyperbaric oxygen therapy appears to be a viable treatment modality in patients with Ficat II FHN.

Brachial plexus injury following spinal surgery

OBJECT In the present study, the authors identified the etiology, precipitating factors, and outcomes of perioperative brachial plexus injuries following spine surgery. METHODS We reviewed all the available literature regarding postoperative/perioperative brachial plexus injuries, with special concern for the patients position during surgery, duration of surgery, the procedure performed, neurological outcome, and prognosis. We also reviewed the utility of intraoperative electrophysiological monitoring for prevention of these complications. RESULTS Patient malpositioning during surgery is the main determining factor for the development of postoperative brachial plexus injury. Recovery occurs in the majority of cases but may require weeks to months of therapy after initial presentation. CONCLUSION Brachial plexus injuries are an increasingly recognized complication following spinal surgery. Proper attention to patient positioning with the use of intraoperative electrophysiological monitoring techniques could minimize injury.

Ketosis, ketogenic diet and food intake control: a complex relationship

Though the hunger-reduction phenomenon reported during ketogenic diets is well-known, the underlying molecular and cellular mechanisms remain uncertain. Ketosis has been demonstrated to exert an anorexigenic effect via cholecystokinin (CCK) release while reducing orexigenic signals e.g., via ghrelin. However, ketone bodies (KB) seem to be able to increase food intake through AMP-activated protein kinase (AMPK) phosphorylation, gamma-aminobutyric acid (GABA) and the release and production of adiponectin. The aim of this review is to provide a summary of our current knowledge of the effects of ketogenic diet (KD) on food control in an effort to unify the apparently contradictory data into a coherent picture.

Effects of isoflurane or propofol on postnatal hippocampal neurogenesis in young and aged rats

An increasing number of in vitro and in vivo studies suggest that anesthesia and surgery could be risk factors for later cognitive impairment in the young and aged brain. General anesthesia has been shown to impair spatial memory in rats and this performance is dependent on hippocampal function and postnatal hippocampal neurogenesis. Anesthetic induced alteration of one or more stages of postnatal hippocampal neurogenesis may in part explain this cognitive impairment following anesthesia. Three different populations of proliferating cells in the dentate gyrus (DG) were labeled with different thymidine analogs (EdU, IdU, and CldU) at 4, 8, and 21 days, respectively, in young (3-month-old) and aged (20-month-old) rats prior to a 3h exposure to isoflurane, control, propofol, or 10% intralipid. 24h following general anesthesia, brains were collected for analysis. The number of cells co-localized with neuronal differentiation and maturation labels with each of the thymidine analogs was quantified. In addition, new cell proliferation 24hr following anesthesia was assessed with anti-Ki67. The effect of anesthesia on astrocytes was also assessed with anti-S100β. Isoflurane or propofol did not affect new cell proliferation, as assessed by Ki67, in the DG of young or aged rats. However, propofol significantly decreased the number of differentiating neurons and increased the number of astrocytes in the DG of young, but not aged, rats. Isoflurane significantly decreased the number of maturing neurons and increased the number of astrocytes in the DG of aged, but not young, rats. Isoflurane and propofol anesthesia altered postnatal hippocampal neurogenesis in an age and agent dependent matter.

Delayed ischaemia of the hand necessitating amputation after radial artery cannulation

We present a case of ischaemic hand injury in a patient, who had 95% occlusion of both the ulnar and radial arteries, after atraumatic placement of a left radial artery catheter. The presence of cigarette burns on the dorsum of the hand was highly suggestive of vascular compromise. There were no signs of vascular compromise after placement of the arterial line which was removed 24 hr later. Ten days after placement the patient complained of pain with ensuing ischaemic changes resulting in necrosis of the finger tips and eventual amputation of the hand. We recommend using other sites of arterial access such as axillary or superficial temporal artery in patients with severe peripheral vascular disease.RésuméNous présentons un cas de lésion ischémique de la main survenue chez un patient qui a developpé une occlusion à 95% des artères radiales et cubitales après l’insertion atraumatique d’une canule radiale gauche. La présence de brûlures de cigarettes sur le dos de la main suggérait déjà une atteinte vasculaire. On n’pas noté de signes d’ischémie après l’installation de la canule qui fut retirée après 24 heures. Dix jours après l’insertion, le patient s’est plaint d’une doubleur suivie de changements ischémique évoluant vers une nécrose du bout des doigts et d’une amputation. Nous recommandons l’utilisation d’accès artériels différents comme les artères temporales superficielles ou axillaires chez les porteurs de maladies vasculaires périphériques.

Plasma Free Hemoglobin Is an Independent Predictor of Mortality among Patients on Extracorporeal Membrane Oxygenation Support

Background Hemolysis is common in all extracorporeal circuits as evident by the elevated plasma free hemoglobin (PFHb) level. We investigated whether increased hemolysis during extracorporeal membrane oxygenation (ECMO) is an independent mortality predictor. Methods We performed a retrospective observational study of consecutive subjects who received ECMO at a tertiary care facility from 2007-2013 to investigate independent predictors of in-hospital mortality. We examined variables related to patient demographics, comorbidities, markers of hemolysis, ECMO characteristics, transfusion requirements, and complications. 24-hour PFHb> 50 mg/dL was used as a marker of severe hemolysis. Results 154 patients received ECMO for cardiac (n= 115) or pulmonary (n=39) indications. Patients’ mean age was 51 years and 75.3% were males. Compared to nonsurvivors, survivors had lower pre-ECMO lactic acid (p=0.026), lower 24-hour lactic acid (p=0.023), shorter ECMO duration (P=0.01), fewer RBC transfusions on ECMO (p=0.008) and lower level of PFHb 24-hours post ECMO implantation (p=0.029). 24-hour PFHb> 50 mg/dL occurred in 3.9 % versus 15.5% of survivors and nonsurvivors, respectively, p=0.002. A Cox proportional hazard analysis identified PFHb> 50 mg/dL 24-hours post ECMO as an independent predictor of mortality (OR= 3.4, 95% confidence interval: 1.3 – 8.8, p= 0.011). Conclusion PFHb> 50 mg/dL checked 24-hour post ECMO implantation is a useful tool to predict mortality. We propose the routine checking of PFHb 24-hours after ECMO initiation for early identification and treatment of the cause of hemolysis.