William Li Pi Shan

Initial Results of Posterior Leaflet Extension for Severe Type IIIb Ischemic Mitral Regurgitation

Background— Management of severe ischemic mitral regurgitation remains difficult with disappointing early and intermediate-term surgical results of valve repair. Methods and Results— Forty-four patients with severe (4+) Carpentier type IIIb ischemic mitral regurgitation underwent mitral valve repair, with or without surgical revascularization, by posterior leaflet extension with a patch of bovine pericardium and a remodeling annuloplasty. Serial echocardiography was performed preoperatively, intraoperatively, and postoperatively to assess mitral valve competence. The postoperative functional status of patients was assessed. The average Parsonnet score was 38±13. Thirty-day mortality was 11%, and late mortality was 14%. Mean follow-up was 38 months. The actuarial freedom from moderate or severe recurrent mitral regurgitation was 90% at 2 years, whereas 90% of patients were in New York Heart Association class I at 2 years. Conclusion— Posterior leaflet extension with annuloplasty of the mitral valve for severe type IIIb ischemic regurgitation is a safe, effective method that provides good early and intermediate-term competence of the mitral valve and therefore good functional status.

Fasting blood glucose levels in patients presenting for elective surgery

OBJECTIVE The incidence of diabetes mellitus (DM) is increasing worldwide; however, its diagnosis is often delayed. Identifying patients with abnormal fasting blood glucose (FBG) levels preoperatively may have important implications for immediate and long-term outcomes. The aim of the present study was to determine the prevalence of impaired fasting glucose (IFG) and provisional diagnosis of DM (PDD) with potential risk factors in patients presenting for elective surgery. METHODS We measured FBG in consecutive adult patients undergoing elective non-cardiac surgery from September 2006 to August 2007. Patient age, sex, body mass index, and FBG were collected in the morning of their scheduled intervention. FBG was classified according to the World Health Organization categorization. Patients with a history of DM were excluded from the final analysis. The prevalence of IFG and PDD and odds ratio for risk factors were calculated. RESULTS Four hundred ninety-three patients without a prior diagnosis of DM were sampled; 19.3% (95 of 493) had IFG and 6.5% (32 of 493) had PDD. Male subjects had a greater risk of PDD than female subjects (odds ratio 2.5, 95% confidence interval 1.2-5.5, P = 0.017). Increased body mass index was not a risk factor for IFG or PDD. The prevalence of IFG but not of PDD had a tendency to increase with age after 40 y. CONCLUSION More than 25% of patients without a prior diagnosis of DM presenting for elective surgery had increased FBG levels. Obtaining this information may initiate not only an earlier detection of DM in some patients but also affect acute perioperative management and outcomes.

Predicting early epidurals: association of maternal, labor, and neonatal characteristics with epidural analgesia initiation at a cervical dilation of 3 cm or less

Background Retrospective studies have associated early epidural analgesia with cesarean delivery, but prospective studies do not demonstrate a causal relationship. This suggests that there are other variables associated with early epidural analgesia that increase the risk of cesarean delivery. This study was undertaken to determine the characteristics associated with early epidural analgesia initiation. Methods Information about women delivering at 37 weeks or greater gestation with epidural analgesia, who were not scheduled for cesarean delivery, was extracted from the McGill Obstetric and Neonatal Database. Patients were grouped into those who received epidural analgesia at a cervical dilation of ≤3 cm and >3 cm. Univariable and multivariable logistic regression was used to determine the maternal, neonatal, and labor characteristics that increased the risk of inclusion in the early epidural group. Results Of the 13,119 patients analyzed, multivariable regression demonstrated odds ratios (OR) of 2.568, 5.915 and 10.410 for oxytocin augmentation, induction, and dinoprostone induction of labor (P < 0.001). Increasing parity decreased the odds of early epidural analgesia (OR 0.780, P < 0.001), while spontaneous rupture of membranes (OR 1.490) and rupture of membranes before labor commenced (OR 1.288) were also associated with early epidural analgesia (P < 0.001). Increasing maternal weight (OR 1.049, P = 0.002) and decreasing neonatal weight (OR 0.943, P < 0.001) were associated with increasing risk of early epidural analgesia. Conclusion Labor augmentation and induction, nulliparity, rupture of membranes spontaneously and before labor starts, increasing maternal weight, and decreasing neonatal weight are associated with early epidural analgesia. Many of these variables are also associated with cesarean delivery.

Upper airway compromise secondary to edema in Graves’ disease

PurposeWe report an unusual case of upper airway compromise in a patient with Graves’ disease. We speculate that this complication may be due, in part, to poorly controlled hyperthyroidism.Clinical featuresA 26-yr-old female suffering from Graves’ disease underwent a total thyroidectomy. Awake fibreoptic intubation was attempted because of a large goiter and orthopnea. Upper airway edema impeded the passage of an armored 7.5 mm endotracheal tube. She was subsequently intubated awake with a regular 7.5 mm endotracheal tube under direct laryngoscopy over an Eschmann bougie. The patient was extubated in the operating room over a tube exchanger. Two hours later she developed stridor and upper airway obstruction. Using direct laryngoscopy, she was reintubated with difficulty because of upper airway edema. At this time, she manifested signs of thyrotoxicosis which were managed medically. On postoperative day three she underwent a tracheostomy after failing a trial of extubation. The upper airway was edematous with minimal vocal cord movement. On postoperative day nine the tracheostomy was downsized and the patient was sent home. The vocal cords were still edematous with minimal movement. Three weeks later, she demonstrated normal right vocal cord movement and weak left vocal cord movement, and the tracheostomy was decannulated.ConclusionsUncontrolled hyperthyroid patients with large goiters secondary to Graves’ disease may develop edema of the upper airway. A high degree of vigilance for airway obstruction is necessary, with a carefully planned approach at each stage of the patient’s hospital course to treat this potentially life-threatening situation.RésuméObjectifPrésenter un cas inhabituel ďatteinte des voies aériennes supérieures chez une patiente atteinte de la maladie de Graves. Nous avons pensé que cette complication relevait, en partie, du traitement inadéquat de ľhyperthyroïdie.Éléments cliniquesUne femme de 26 ans atteinte de la maladie de Graves a subi une thyroïdectomie totale. Ľintubation fibroscopique vigile a été tentée à cause ďun goitre important et ďorthopnée. Un œdème des voies aériennes supérieures empêchait le passage ďun tube endotrachéal renforcé de 7,5 mm. La patiente a été intubée éveillée avec un tube endotrachéal régulier de 7,5 mm sous laryngoscopie directe au-dessus ďune bougie de Eschmann. Elle a été extubée dans la salle ďopération à ľaide ďun tube ďéchange. Deux heures plus tard, un stridor s’est développé et une obstruction des voies aériennes. Elle a été difficilement réintubée sous laryngoscopie directe à cause ďun œdème. Des signes de thyrotoxicose apparus à ce moment ont été traités médicalement. Au troisième jour postopératoire, elle a subi une trachéostomie après ľéchec de ľextubation. Les voies aériennes supérieures étaient œdémateuses et le mouvement des cordes vocales minimal. Au neuvième jour, la trachéostomie a été réduite et la patiente a quitté ľhôpital. Les cordes vocales étaient toujours œdématiées et peu mobiles. Trois semaines plus tard, la corde vocale droite bougeait normalement et la corde vocale gauche, faiblement. La canule de trachéostomie a été retirée.ConclusionLes patients atteints ďhyperthyroïdie non contrôlée et ďun goitre important secondaires à la maladie de Graves peuvent avoir un œdème des voies respiratoires supérieures. Il faut penser à la possibilité ďobstruction et planifier une approche rigoureuse pour chaque étape de ľhospitalisation afin de traiter cette situation potentiellement dangereuse.Objectif Presenter un cas inhabituel ďatteinte des voies aeriennes superieures chez une patiente atteinte de la maladie de Graves. Nous avons pense que cette complication relevait, en partie, du traitement inadequat de ľhyperthyroidie.

Atteinte des voies aériennes supérieures secondaire à un œdème dans la maladie de Graves

PurposeWe report an unusual case of upper airway compromise in a patient with Graves’ disease. We speculate that this complication may be due, in part, to poorly controlled hyperthyroidism.Clinical featuresA 26-yr-old female suffering from Graves’ disease underwent a total thyroidectomy. Awake fibreoptic intubation was attempted because of a large goiter and orthopnea. Upper airway edema impeded the passage of an armored 7.5 mm endotracheal tube. She was subsequently intubated awake with a regular 7.5 mm endotracheal tube under direct laryngoscopy over an Eschmann bougie. The patient was extubated in the operating room over a tube exchanger. Two hours later she developed stridor and upper airway obstruction. Using direct laryngoscopy, she was reintubated with difficulty because of upper airway edema. At this time, she manifested signs of thyrotoxicosis which were managed medically. On postoperative day three she underwent a tracheostomy after failing a trial of extubation. The upper airway was edematous with minimal vocal cord movement. On postoperative day nine the tracheostomy was downsized and the patient was sent home. The vocal cords were still edematous with minimal movement. Three weeks later, she demonstrated normal right vocal cord movement and weak left vocal cord movement, and the tracheostomy was decannulated.ConclusionsUncontrolled hyperthyroid patients with large goiters secondary to Graves’ disease may develop edema of the upper airway. A high degree of vigilance for airway obstruction is necessary, with a carefully planned approach at each stage of the patient’s hospital course to treat this potentially life-threatening situation.RésuméObjectifPrésenter un cas inhabituel ďatteinte des voies aériennes supérieures chez une patiente atteinte de la maladie de Graves. Nous avons pensé que cette complication relevait, en partie, du traitement inadéquat de ľhyperthyroïdie.Éléments cliniquesUne femme de 26 ans atteinte de la maladie de Graves a subi une thyroïdectomie totale. Ľintubation fibroscopique vigile a été tentée à cause ďun goitre important et ďorthopnée. Un œdème des voies aériennes supérieures empêchait le passage ďun tube endotrachéal renforcé de 7,5 mm. La patiente a été intubée éveillée avec un tube endotrachéal régulier de 7,5 mm sous laryngoscopie directe au-dessus ďune bougie de Eschmann. Elle a été extubée dans la salle ďopération à ľaide ďun tube ďéchange. Deux heures plus tard, un stridor s’est développé et une obstruction des voies aériennes. Elle a été difficilement réintubée sous laryngoscopie directe à cause ďun œdème. Des signes de thyrotoxicose apparus à ce moment ont été traités médicalement. Au troisième jour postopératoire, elle a subi une trachéostomie après ľéchec de ľextubation. Les voies aériennes supérieures étaient œdémateuses et le mouvement des cordes vocales minimal. Au neuvième jour, la trachéostomie a été réduite et la patiente a quitté ľhôpital. Les cordes vocales étaient toujours œdématiées et peu mobiles. Trois semaines plus tard, la corde vocale droite bougeait normalement et la corde vocale gauche, faiblement. La canule de trachéostomie a été retirée.ConclusionLes patients atteints ďhyperthyroïdie non contrôlée et ďun goitre important secondaires à la maladie de Graves peuvent avoir un œdème des voies respiratoires supérieures. Il faut penser à la possibilité ďobstruction et planifier une approche rigoureuse pour chaque étape de ľhospitalisation afin de traiter cette situation potentiellement dangereuse.Objectif Presenter un cas inhabituel ďatteinte des voies aeriennes superieures chez une patiente atteinte de la maladie de Graves. Nous avons pense que cette complication relevait, en partie, du traitement inadequat de ľhyperthyroidie.

Potential pitfalls of interim analysis

trade. Our graduates should have some understanding of the processes involved and the importance of research, and should appreciate the need to support the efforts of those who do become involved in research. Just as students are expected to be familiar with calculus and organic chemistry before entering medical school (with no expectation of their becoming mathematicians or chemists), it is important for our residents to understand how the information in our clinical textbooks was generated from basic science and clinical research. We thank the correspondents for their helpful comments and we are grateful for the opportunity to clarify our position. We must also re-emphasize that it was never our intention to capture absolute numbers of publications. Instead, our intent was to examine the trends of research activity taking place in Anesthesiolgy Departments across the country, regardless of the number of individuals involved. We hope that we captured most, if not all, of the most important work published in our discipline during the period in question. If we did not do so, we are truly disappointed.