Rachel Karlnoski

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.

Suppression of Amyloid Deposition Leads to Long-Term Reductions in Alzheimer's Pathologies in Tg2576 Mice

In amyloid precursor protein (APP) models of amyloid deposition, the amount of amyloid deposits increase with mouse age. At a first approximation, the extent of amyloid accumulation may either reflect small excesses of production over clearance that accumulate over time or, alternatively, indicate a steady-state equilibrium at that age, reflecting the instantaneous excess of production over clearance, which increases as the organism ages. To discriminate between these options, we reversibly suppressed amyloid deposition in Tg2576 mice with the anti-Aβ antibody 2H6, starting at 8 months, just before the first histological deposits can be discerned. Six months later, we stopped the suppression and monitored the progression of amyloid accumulation in control APP mice and suppressed APP mice over the next 3 months. The accumulation hypothesis would predict that the rate of amyloid from 14 to 17 months would be similar in the suppressed and control mice, while the equilibrium hypothesis would predict that the increase would be faster in the suppressed group, possibly catching up completely with the control mice. The results strongly support the accumulation hypothesis, with no evidence of the suppressed mice catching up with the control mice as predicted by equilibrium models. If anything, there was a slower rate of increase in the suppressed APP mice than the control mice, suggesting that a slow seeding mechanism likely precedes a rapid fibrillogenesis in determining the extent of amyloid deposition.

Quantitative assessment of new cell proliferation in the dentate gyrus and learning after isoflurane or propofol anesthesia in young and aged rats

There is a growing body of evidence showing that a statistically significant number of people experience long-term changes in cognition after anesthesia. We hypothesize that this cognitive impairment may result from an anesthetic-induced alteration of postnatal hippocampal cell proliferation. To test this hypothesis, we investigated the effects of isoflurane and propofol on new cell proliferation and cognition of young (4 month-old) and aged (21 month-old). All rats were injected intraperitoneally (IP) with 50 mg/kg of 5-bromo-2-deoxyuridine (BrdU) immediately after anesthesia. A novel appetitive olfactory learning test was used to assess learning and memory two days after anesthesia. One week after anesthesia, rats were euthanized and the brains analyzed for new cell proliferation in the dentate gyrus, and proliferation and migration of newly formed cells in the subventricular zone to the olfactory bulb. We found that exposure to either isoflurane (p=0.017) or propofol (p=0.006) decreased hippocampal cell proliferation in young, but not in aged rats. This anesthetic-induced decrease was specific to new cell proliferation in the hippocampus, as new cell proliferation and migration to the olfactory bulb was unaffected. Isoflurane anesthesia produced learning impairment in aged rats (p=0.044), but not in young rats. Conversely, propofol anesthesia resulted in learning impairment in young (p=0.01), but not in aged rats. These results indicate that isoflurane and propofol anesthesia affect postnatal hippocampal cell proliferation and learning in an age dependent manner.

Voluven, a new colloid solution.

Hydroxyethyl starch (HES) 130/0.4 (Voluven, Fresenius/Hospira, Germany) is indicated for the treatment and prophylaxis of hypovolemia. As the Voluven molecule is smaller than those of other available hydroxyethyl starch products, it is associated with less plasma accumulation and can be safely used in patients with renal impairment. Previous studies have demonstrated that Voluven has comparable effects on volume expansion and hemodynamics as other available HES products. Voluven is also associated with fewer effects on coagulation and may be an acceptable alternative to albumin for volume expansion in situations in which other starches are contraindicated secondary to risk of coagulopathy.

Intravenous acetaminophen vs. ketorolac for postoperative analgesia after ambulatory parathyroidectomy

Abstract Background and methods Minimally invasive parathyroidectomy requires limited analgesia and short recovery times. The preferred post-operative analgesic regimen for this patient population has not been established but non-narcotic components would be quite appropriate. The aim of the study was to determine whether intravenous (IV) acetaminophen (1 g) or ketorolac (30 mg) provide better pain control after parathyroidectomy. A parallel, randomized, double blind, comparative study was completed on 180 patients scheduled for outpatient parathyroidectomy utilizing general anesthesia. Patients were randomized to a blinded administration of either intravenous acetaminophen 1 g or ketorolac 30 mg intra-operatively. Upon arrival but before premedication, baseline pain scores were assessed in all patients. A consecutive series of postoperative pain scores were collected every 15 min using a 10 cm visual analog pain scale (VAS) upon arrival to the post anesthesia care unit (PACU) until discharge by blinded study personnel. Other data collected included: anesthesia time, surgical time, time to discharge, supplemental morphine and postoperative side effects. Results Overall mean postoperative VAS scores were not significantly different between the two treatment groups (p = 0.07). However, ketorolac produced significantly lower pain scores compared with acetaminophen in the later postoperative periods (3.9 ± 1.9 vs. 4.8 ± 2.4 at 45 min, p = 0.009; 3.4 ± 1.7 vs. 4.5 ± 2.1 at 60min, p = 0.04; and 3.2 ± 2.1 vs. 4.4 ± 2.1 at 75 min, p = 0.03). Supplemental morphine was administered to 3 patients in the ketorolac group and 9 patients in the acetaminophen group but total consumption was not significantly different between groups (p = 0.13). The occurrence of nausea was significantly lower in the ketorolac group compared with the IV acetaminophen group (3.4% vs. 14.6%, respectively; p = 0.02). The overall incidence of morphine supplementation, vomiting, headache, muscular pain, dizziness, and drowsiness were not significantly different when compared between the treatment groups. Conclusions Both postoperative regimens provided adequate analgesia but patients receiving ketorolac intraoperatively had significantly lower pain scores at later recovery time points and significantly lower occurrences of nausea. Implications The large volume of patients undergoing parathyroidectomies at our facility warranted a study to develop a standardized postoperative analgesic regimen. We conclude both medications can be utilized safely in this patient population, but there is a slight advantage in pain control with the usage of ketorolac for minimally invasive parathyroidectomies.

Intravascular balloon to minimize blood loss during total hip replacement in a Jehovah's Witness

Intermittent intravascular occlusive balloons are commonly used to minimize bleeding in cases where massive blood loss is anticipated. However, the efficiency and safety of balloon occlusion remains unclear for elective procedures, and several cases of distal thrombosis have been reported. A case of intra-arterial occlusive balloon that was selectively placed preoperatively to minimize bleeding in a patient during total hip replacement is presented. Use of an external tourniquet was not feasible for this patient. The balloon was inflated to a minimum volume to achieve intravascular occlusion and was periodically deflated to minimize the risk of postoperative complications. A surgical field with minimal blood loss was created.

An Analysis of Inhalation Injury Diagnostic Methods and Patient Outcomes.

The purpose of this study was to compare patient outcomes according to the method of diagnosing burn inhalation injury. After approval from the American Burn Association, the National Burn Repository Dataset Version 8.0 was queried for patients with a diagnosis of burn inhalation injury. Subgroups were analyzed by diagnostic method as defined by the National Burn Repository. All diagnostic methods listed for each patient were included, comparing mortality, hospital days, intensive care unit (ICU) days, and ventilator days (VDs). Z-tests, t-tests, and linear regression were used with a statistical significance of P value of less than .05. The database query yielded 9775 patients diagnosed with inhalation injury. The greatest increase in mortality was associated with diagnosis by bronchoscopy or carbon monoxide poisoning. A relative increase in hospital days was noted with diagnosis by bronchoscopy (9 days) or history (2 days). A relative increase in ICU days was associated with diagnosis according to bronchoscopy (8 days), clinical findings (2 days), or history (2 days). A relative increase in VDs was associated with diagnosis by bronchoscopy (6 days) or carbon monoxide poisoning (3 days). The combination of diagnosis by bronchoscopy and clinical findings increased the relative difference across all comparison measures. The combination of diagnosis by bronchoscopy and carbon monoxide poisoning exhibited decreased relative differences when compared with bronchoscopy alone. Diagnosis by laryngoscopy showed no mortality or association with poor outcomes. Bronchoscopic evidence of inhalation injury proved most useful, predicting increased mortality, hospital, ICU, and VDs. A combined diagnosis determined by clinical findings and bronchoscopy should be considered for clinical practice.

Bloodless Surgery by a Regional Intra- arterial Tourniquet During Primary and Revision THA

Primary total hip arthroplasty (THA) and revision THA are associated with blood loss that can be significant. The purpose of this retrospective study was to compare the efficacy of intra-arterial occlusive balloons in reducing blood loss during primary and revision THA. Twelve patients (Jehovah’s Witnesses) scheduled for a primary (n=6) or revision (n=6) THA who refused blood transfusions were compared with 48 control-matched patients (primary THA, n=24; revision THA, n=24). All Jehovah’s Witnesses received an intra-arterial balloon preoperatively, and all control patients underwent conventional surgery. Intraoperatively, balloons were periodically inflated to reduce blood loss and deflated to prevent limb ischemia. Endpoints for the study were estimated blood loss, perioperative hemoglobin, mean hospital stay, mean operative time, amount of intraoperative fluid or blood administered, and complications. None of the patients with an occlusive balloon received blood, whereas the primary THA group received an average of 0.6 units (P=.08) and the revision THA group received an average of 1.9 units (P=.02). Estimated blood loss was significantly decreased in the balloon group compared with the primary THA group (145 vs 402 mL, respectively; P<.01) and the revision THA group (333 vs 767 mL, respectively; P<.01). No complications were associated with the intra-arterial balloons. All patients showed a significant reduction in hemoglobin immediately postoperatively compared with preoperative values. No statistically significant differences existed in the amount of fluids given intraoperatively or the mean hospital stay among all groups. Temporary internal tourniquets used as an adjuvant to surgery significantly reduce intraoperative blood loss during primary and revision THA.

Rapid onset of guillain-barré syndrome after an obstetric epidural block.

Reports of acute onset of Guillain-Barré syndrome (GBS) after epidural anesthesia/analgesia after labor and cesarean delivery has raised concern of a correlation between GBS and the use of neuraxial anesthesia. We present a patient who developed bilateral lower extremity weakness and paraparesis within hours after removal of an epidural catheter for cesarean delivery. The clinical diagnosis was highly suggestive for GBS after magnetic resonance imaging, cerebrospinal fluid findings, electromyogram, and nerve conduction studies. We discuss the pathophysiological mechanisms suggested in previous case reports and describe the relationship between epidural analgesia and GBS.

Simultaneous left anterior descending and right coronary stent thrombosis after aspirin withdrawal

ST-segment elevation myocardial infarction is usually caused by plaque rupture and subsequent thrombosis of a single culprit vessel. In rare occasions, simultaneous thrombosis of 2 coronary arteries occurs, which is usually associated with a worse prognosis. Although surgery provokes hemodynamic stress, leading in some instances to myocardial ischemia due to supply/demand mismatch, other factors may also contribute to postoperative myocardial infarction. We present a case of postoperative simultaneous left anterior descending and right coronary stent thrombosis that followed cessation of long-term aspirin therapy in a patient with stable coronary artery disease. This case raises concerns with drug-eluting stents due to the higher potential for late stent thrombosis related to delayed endothelialization of the stent struts. Physicians should be very cautious when deciding to withdraw antiplatelet therapy preoperatively to avoid rebound coronary thrombosis.