Vadim Khazin

Save a child’s heart: we can and we should

BACKGROUND Congenital heart disease (CHD) causes the death of thousands of children in developing countries. At the Wolfson Medical Center (WMC), a prototype program has been developed to address this issue. METHODS Since 1996, indigent children have been referred to the program, with the cooperation of partners in developing countries. The projects aims are to (a) train their medical personnel at WMC, (b) travel to participating countries to teach, evaluate patients, operate, and promote the development of local centers, and (c) treat children with CHD, at WMC, who lack a local option for care either due to prohibitive costs or unavailability. The projects personnel are state employees who volunteer to treat additional patients within the framework of their salaries, and community volunteers. RESULTS The program has seven partner sites in six countries, including two provinces in China (Hebei and Gansu), Ethiopia, Moldova, Nigeria, the Palestinian Authority, and Tanzania. Five physicians and 10 nurses have been trained from five participating countries. Over the past 4 years, 11 teaching trips have been made abroad, and operations have been performed at four partner sites. A total of 386 patients have been operated on-360 at WMC and 26 at other sites. There have been 17 (4.3%) acute deaths. Follow-up is 92% complete with 3 late deaths reported. CONCLUSIONS Hospital-based regional centers can be created to promote the care of children with CHD in developing countries. Good results and follow-up care can be provided with appropriate planning.

Distribution of cerebral flow using retrograde versus antegrade cerebral perfusion

BACKGROUND This study compared flow to the brain with retrograde and antegrade cerebral perfusion during circulatory arrest. METHODS Twenty-four rabbits were injected with 5 mCi of technetium-99 macroaggregated albumin, a tracer trapped in the capillaries. Group I (n = 6) were maintained normothermic, and the tracer was injected into the ascending aorta. Group II (n = 6) were maintained normothermic, and underwent cannulation of the superior vena cava (SVC), exsanguination through the aorta, and injection of the tracer into the SVC, which was proximally occluded. In group III (n = 6), the animal was cooled to 25 degrees C. The animal was exsanguinated through the aorta and tracer was injected into the ascending aorta. In group IV (n = 6), animals were cooled to 25 degrees C. The animal was exsanguinated through the ascending aorta and tracer was injected into the SVC. Three animals (group V) were exsanguinated through the ascending aorta and a retrograde venogram of the SVC was performed. Scintigraphy of groups I to IV was carried out on a digital gamma camera. Brain trapping of tracer was graded from 0 to 5, with 0 being no tracer in the brain and 5 being dominant tracer trapping in the brain. RESULTS Tracer trapping in the brain showed group I, 3.67+/-0.82; group II, 0; group III, 4.67+/-0.41; group IV, 0.17+/-0.41 (p<0.0001). Retrograde venogram of the SVC showed flow into the cerebral veins. CONCLUSIONS Retrograde flow through the SVC reaches the cerebral venous system. Flow arriving in retrograde fashion does not go through the capillary system.

The effect of intermittent versus continuous bladder catheterization on labor duration and postpartum urinary retention and infection: a randomized trial

STUDY OBJECTIVE To assess the effect of intermittent versus continuous bladder catheterization on labor duration and local anesthetic consumption. DESIGN Randomized, controlled, prospective, single-blind trial. SETTING University-affiliated hospital. PATIENTS 209 ASA physical status I and II, primiparous parturients who received patient-controlled epidural analgesia for labor. INTERVENTIONS Patients were randomly allocated to either the intermittent bladder catheterization group (Group IC; n = 109) or the continuous catheterization group (Group CC; n = 100). MEASUREMENTS Duration of the second stage of labor, dose of local anesthetics given, and primary outcomes were compared by group using the t-test for independent samples. Main secondary outcomes were postpartum urinary retention and rate of postpartum urinary tract infection (UTI; asymptomatic bacteruria). MAIN RESULTS Duration of the second stage of labor was longer in Group CC than Group IC: 105 +/- 72 vs. 75 +/- 52 min (P = 0.002). This finding was associated with increased local anesthetic dose requirement in Group CC during both stages of labor (73 +/- 25 mL vs. 63 +/- 26 mL; P = 0.005). The rate of UTI was similar (30%) in both study groups. CONCLUSION Intermittent bladder catheterization was associated with shorter second-stage labor and less local anesthetic, but the same frequency of postpartum urinary retention and UTI was seen with both catheterization groups.

Predistention of the epidural space before catheter insertion reduces the incidence of intravascular epidural catheter insertion

BACKGROUND:Accidental cannulation of an epidural vein is a common complication associated with epidural anesthesia or analgesia. On the basis of a pilot study and previous reports, we tested the hypothesis that predistention of the epidural space with saline before epidural catheterization would ease catheter insertion and decrease the incidence of this complication. METHODS:Two-hundred-three laboring women were randomly assigned to receive an epidural with loss of resistance technique with 2 mL (nondistention) or 5 mL saline (distention). In the distention group, the syringe plunger was held closed before epidural catheter insertion. Then in both groups, a test dose of 3 mL of 1.5% lidocaine was injected through the epidural catheter. RESULTS:There were fewer accidental intravascular catheter placements (2% vs 16%, P = 0.0001) in the distention group, and 91% of patients in this group did not have any unblocked segments versus 67% in the nondistension group (P = 0.0001). The difference in onset time of analgesia was small (5.0 ± 2 min vs 6 ± 3 min, P = 0.0001) and not clinically important. The quality of analgesia (visual analog scores and ropivacaine consumption) was similar between groups. CONCLUSIONS:Distention of the epidural space with 5 mL saline before epidural catheter insertion decreased the incidence of accidental venous cannulation and the number of unblocked segments.

Gastroesophageal regurgitation during anesthesia and controlled ventilation with six airway devices

STUDY OBJECTIVE To investigate the frequency of gastroesophageal regurgitation and respiratory mechanics during positive pressure ventilation using 5 supraglottic devices or an endotracheal tube (ETT). DESIGN Prospective, randomized study. SETTING Operating rooms in a university-affiliated hospital. PATIENTS 180 ASA physical status I and II patients, aged 18 to 65 years old, who underwent elective orthopedic, minor vascular, peripheral plastic, or urologic surgery during general anesthesia. INTERVENTIONS Patients were randomly allocated to one of 6 airway device groups (n = 30 each): (1) Cobra Perilaryngeal Airway; (2) Laryngeal Mask Airway (LMA) Classic; (3) LMA Fastrach; (4) LMA ProSeal; (5) laryngeal tube; and (6) ETT (SIMS Portex, Ltd, Hythe, Kent, UK). After insertion of the designated device, the lungs of each nonparalyzed patient were mechanically ventilated. MEASUREMENTS Hypopharyngeal pH, peak inspiratory pressures, sealing pressures, and lung compliance were measured. Hypopharyngeal pH lower than 4 was considered a regurgitation event. MAIN RESULTS Regurgitation (episodes of pH <4) occurred in between one and 5 patients of each study group, with no statistical difference. Sealing pressures were similar among all the airway device groups. CONCLUSIONS The frequency of gastroesophageal regurgitation in anesthetized, unparalyzed, mechanically ventilated patients was similar in patients whose lungs were ventilated with either the Cobra Perilaryngeal Airway, LMA Classic, Fastrach, ProSeal, laryngeal tube, or ETT.

Difficult laryngoscopy: incidence and predictors in patients undergoing coronary artery bypass surgery versus general surgery patients.

OBJECTIVE Cardiac surgery patients might have a higher incidence of difficult laryngoscopy than the general population because of older age, dental problems, and obesity. The authors estimated the incidence and predictors of difficult laryngoscopy in coronary artery bypass surgery patients. DESIGN Prospective, controlled study. SETTING University setting. PARTICIPANTS Patients undergoing coronary artery bypass or general surgery. INTERVENTIONS Two hundred consecutive patients undergoing coronary artery bypass graft and 444 general surgery patients, all aged >40 years, were compared for the incidence and predictors of difficult laryngoscopy, defined as a grade III or IV view. MEASUREMENTS AND MAIN RESULTS Predictors of difficult laryngoscopy were considered mouth opening <4 cm, limited cervical mobility, thyromental distance <6 cm, protruding or partially missing upper teeth, and Mallampati classes 3 and 4. More cases of difficult laryngoscopy were recorded in cardiac patients (10% v 5.2%, p <0.023). The cardiac patients were older, mostly men, and belonged to ASA III-IV risk classes. Mallampati classes 3 and 4 were more frequent in the control group. With univariate analysis, difficult laryngoscopy correlated with 7 variables: older age, ASA-IV risk class, protruding or partially missing upper teeth, limited mouth opening, limited neck movement, thyromental distance <6 cm, and diabetes mellitus. Multivariate analysis adjusted for propensity score identified older age (odds ratio = 1.05/yr, 95% confidence interval = 1.005-1.09, p < 0.03) and limited neck movement (odds ratio = 9.5, 95% confidence interval = 2.2-41, p < 0.003), but not cardiac surgery per se, as independent predictors of difficult laryngoscopy. CONCLUSIONS Difficult laryngoscopy was more frequent in cardiac surgery patients (10% v 5.2%). Older age and limited neck movement, but not cardiac surgery per se, were independent predictors of difficult laryngoscopy.

Postoperative analgesia with tramadol and indomethacin for diagnostic curettage and early termination of pregnancy

BACKGROUND The postoperative analgesic effects of rectal indomethacin and tramadol were compared in patients undergoing elective termination of first trimester pregnancy and diagnostic dilatation and curettage. METHODS Eighty-one American Society of Anesthesiologists class I and II women undergoing first trimester termination of pregnancy or diagnostic dilation and curettage were randomly allocated to receive rectal suppositories of either tramadol 100 mg (n=41) or indomethacin 100 mg (n=40) 90 min before induction of anesthesia. Pain scores and side effects were evaluated until discharge. Intraoperative anesthetic and postoperative analgesic consumption was also recorded. Intravenous metamizole 1 g was employed for postoperative rescue analgesia. RESULTS When compared to the indomethacin group, the tramadol group required less intraoperative propofol [136 mg ±28 vs. 160 mg ±35 (P=0.001)], less rescue analgesia [2.4% vs. 22% (P=0.005)] and lower visual analogue pain scores [2.4 ±8 vs. 23 ±22 (P=0.005)]. The incidence of postoperative nausea and vomiting was similar in both groups. CONCLUSION When compared to indomethacin 100 mg, preoperative administration of tramadol 100 mg provides superior postoperative analgesia with minimal adverse effects.

Removal of deadspace volume from arterial catheter: How muchis enough?

Objective To evaluate the amount of volume needed to be removed from arterial catheter systems to compensate for “deadspace” and to allow an accurate measurement of pH and hemoglobin (Hb). Design Twenty patients undergoing heart surgery were evaluated in a steady state after the induction of anesthesia before surgery. Six blood samples were removed from the arterial catheter, the total volume of which was 1.5 mL at 30-sec intervals and measured for pH and Hb. The first sample was then taken after removing 1.5 mL from the tubing. In subsequent samples, the volume removed before sampling increased by 0.5-mL intervals. All other samples were compared with sample number 6, in which 4 mL of volume were removed before measurements. Results The first three samples with volumes of 1.5, 2.0, and 2.5 mL before measurement were inaccurate compared with sample number 6 (p < .000), giving artificially low values for both pH and Hb. There was no significant difference between the values measured in sample numbers 4, 5, and 6 (3.0, 3.5, and 4.0 mL, respectively). Conclusion The amount of volume needed to be removed before measurement from an arterial catheter system, the volume of which is 1.5 mL, is 3 mL to achieve accurate measurements of pH and Hb. Removal of less volume results in an artificially low measurement.