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At least 487 records · Page 27Linked to original sources
PubMedDate not supplied

Large visible gas bubbles in the internal jugular vein: a common occurrence during supine radical neck surgery?

STUDY OBJECTIVE: To establish the frequency of large visible bubbles or collections of bubbles in the jugular vein during radical neck dissection in the supine position. DESIGN: Prospective observation by at least two investigators of random consecutive patients scheduled for radical neck surgery. SETTING: Operating room suite in a university hospital specializing in head and neck cancer surgery. PATIENTS: Twelve consecutive ASA physical status II and III patients undergoing modified radical dissection for cancer. INTERVENTIONS: General anesthesia with fentanyl, oxygen (O2) 30% to 40%, nitrous oxide (N2O) 60% to 70%, and isoflurane 0.5% to 1.5%, with mechanical ventilation. Table position horizontal. Modified radical neck dissections performed by attending surgeons. Surgical field (jugular vein) carefully observed by the surgeons and an independent anesthesiologist investigator for the presence of bubbles during the dissection. MEASUREMENTS AND MAIN RESULTS: Easily visible bubbles were observed in the jugular veins of 42% (5 of 12) of the consecutive radical neck dissection patients studied. Some of the collections of bubbles were large (greater than 2.5 cm in diameter). In one case, the appearance and subsequent disappearance of bubbles was followed by a transient drop in arterial blood pressure (BP) and in end-tidal carbon dioxide (PETCO2), which was suggestive of a diagnosis of central venous air embolization. CONCLUSIONS: We theorize that some unexplained, undesirable intraoperative events (hypotension, arrhythmia, and hypoxemia) during radical neck dissection could be a result of venous air embolus or paradoxical air embolus. The anesthesia community should be aware of the high frequency of these visible bubbles in the jugular veins during radical neck surgery, even in the supine position. At minimum, this phenomenon is a frequent event of intellectual interest. At worst, these bubbles may be harbingers of significant central air embolism.

Adult↗
PubMed2003

Pleural injury during laparoscopic renal surgery: early recognition and management.

PURPOSE: Injury to the diaphragm is an uncommon yet recognized complication of several laparoscopic procedures, including laparoscopic renal surgery. As these procedures increase in popularity and use, laparoscopic surgeons should be aware of techniques for avoiding this complication as well as methods of identifying pleural injury and managing it appropriately. We report our experience with the detection and intraoperative management of pleural injury sustained during laparoscopic renal surgery and its subsequent treatment. MATERIALS AND METHODS: From July 1993 to April 2001 at 4 institutions 1,765 patients underwent laparoscopic renal surgery for benign and malignant disease as well as for live renal donation. We retrospectively reviewed the charts and interviewed the primary surgeons to determine the etiology of pleural injury, intraoperative detection and management, and possible future prevention. RESULTS: Pleural injury occurred in 10 cases (0.6%). In 2 cases injury involved inadvertent trocar placement through the pleural cavity. These cases were managed by intraoperative chest tube placement. In 8 cases the diaphragm was injured in iatrogenic fashion during kidney dissection, including during splenic mobilization in 2, liver mobilization in 2, ascending colon mobilization in 1, dissection of the upper renal pole in 2 and dissection of a large renal cyst off of the diaphragm in 1. In all patients injury was detected intraoperatively and repaired via laparoscopy. In 1 patient residual pneumothorax postoperatively necessitated tube thoracostomy. CONCLUSIONS: Pleural injury sustained during laparoscopic surgery is an uncommon but potentially serious complication of laparoscopic renal procedures. The experienced laparoscopic surgeon can identify and repair the injury intraoperatively, minimizing patient morbidity postoperatively.

Diaphragm↗
PubMedDate not supplied

Spine deformity in familial dysautonomia (Riley-Day syndrome).

Familial dysautonomia spanning a 30-year period reviewed retrospectively. The 16 patients identified included nine with spine deformities. Serious general medical problems were common. Spine deformities included kyphosis, scoliosis, or a combination of both. Brace treatment was attempted and was unsuccessful in three patients. Seven underwent surgical stabilization. Although all seven patients tolerated the surgical procedures, at least one postoperative complication was noted in each case. Follow-up ranged from 1 1/2 to 16 1/2 years. We recommend close observation of the deformities, early stabilization when disorders are progressive, and a high level of awareness of potential complications.

Adolescent↗
PubMed1989

Management of blindness in the practice of cosmetic surgery.

Blindness (amaurosis) as a complication of cosmetic surgery is not common, but has been reported in cases of blepharoplasty, as well as in connection with facial injection of various substances, including collagen. The anatomic and pathophysiologic basis for embolization of the retinal artery is presented, and the literature regarding thromboembolic, spasmodic, and vaso-obliterative etiologic factors in amaurosis is reviewed. It is recommended that ocular examination be carried out prior to both injection of materials into the face and blepharoplasty. The treatment of this most serious complication is reviewed in detail. Finally, it is suggested that the surgeons who practice cosmetic surgery be aware of this complication and the current treatment modalities.

Adult↗
PubMed2001

Cardiopulmonary bypass with deep hypothermic circulatory arrest for a patient with sickle cell anemia: a case report.

A 36-year-old sickle cell anemia patient undergoing a pulmonary thromboendarterectomy required the use of cardiopulmonary bypass incorporating deep hypothermic circulatory arrest. Being aware of reported incidences of sickling crises, a team of the surgeon, anesthesiologist, hematologist, and perfusionist met to devise a plan of treatment. Treatment included preoperative and intraoperative exchange transfusion, optimal blood gas management, and increased blood flows during bypass. The surgical procedure was performed and was successful in reducing pulmonary hypertension, incorporating a team approach and utilizing these techniques. No incidence of adverse sickling events was observed during this procedure.

Adult↗
PubMed2004

Two cases of intraoperative herniation of the endotracheal tube cuff.

During anaesthesia for elective procedures, 2 dogs developed acute airway obstruction caused by herniation of the endotracheal cuff. This is an uncommon but potentially fatal complication especially when minimal monitoring of the patient leads to late recognition of the condition. The most typical symptoms are decreased thoracic excursions and tidal volume, absence of gas flow through the endotracheal tube, change in the capnographic waves morphology and increased airway pressures. In both cases desaturation of haemoglobin (measured by pulse oximetry) occurred in-between 6 and 8 minutes after cuff herniation. All signs normalised following partial deflation of the cuff. Careful management of cuff pressures especially when nitrous oxide is used, awareness of the condition and monitoring of the patient can prevent fatal consequences.

Airway Obstruction↗
PubMed2004

Revision cochlear implant surgery: causes and outcome.

OBJECTIVE: To review experience with cochlear implant reimplantations, including effect of reinsertion on audiological performance. STUDY DESIGN AND SETTING: Retrospective review of cochlear implant reinsertions in patients seen in a private tertiary neurotologic practice. Forty-three patients (8 adults and 35 children) underwent revision cochlear implant surgery for device failure or upgrade. Findings at initial and repeat operations were noted, including number of electrodes inserted, and speech perception performance data were obtained when available. RESULTS: Five complications occurred in the reinsertion operations, 2 (6%) intraoperative cerebral spinal fluid leaks and 3 (7%) postoperative flap breakdowns with implant extrusion. Number of electrodes inserted was unchanged in 40/43 patients. Speech perception abilities remained stable or improved. CONCLUSION: Cochlear reimplantation is technically feasible and allows for continued auditory stimulation. SIGNIFICANCE: Patients facing reimplantation must be aware of the possibility of differences in sound quality and speech recognition performance with their replacement device, but speech perception ability will typically remain the same or improve.

Adult↗
PubMed1987

Corneal epithelial healing after penetrating keratoplasty using topical Healon versus balanced salt solution.

The authors conducted a prospective study of 38 consecutive corneal transplant patients over a five-and-one-half month period in order to evaluate the effect of intraoperative hydration with topical Healon versus balanced salt solution on postoperative epithelial healing in the corneal graft. Eight independent variables, including patient age, sex, operating room time, donor age, donor time in McCarey-Kaufman media, intraoperative hydration with balanced salt solution versus Healon, and the amount of postoperative punctate epithelial keratitis measured on postoperative day 1, day 2, and at one week were compared using a multiple linear regression method. While the correlation between donor age (p = .060) and patient age (p = .088) with the amount of punctate epithelial keratitis at one week post graft approached statistical significance, only the Healon-treated group showed a high correlation to more complete graft healing one week postoperatively (p = 0.002). Topical Healon during keratoplasty may foster epithelial healing, but it also may present technical challenges of which the surgeon should be aware.

Adult↗
PubMed1998

Cochlear implantation in children with inner ear malformations.

We performed a case study and intervention study, with follow-up of 1 to 5 years, in 4 children with inner ear malformations who underwent implantation of a multichannel cochlear implant (Nucleus, Cochlear Corporation) at ages 3 to 12 years. Malformations included a common cavity deformity, 2 incomplete partitions, and 1 case of isolated bilateral vestibular aqueduct enlargement. One child had a single-channel implant placed at 3 years of age, and this was exchanged for a 22-channel implant at age 9. One child had her implant placed at age 4.5 years, but due to complications from a cerebrospinal fluid (CSF) leak had the initial implant removed and replaced at age 5 years during repair of the CSF leak. Intraoperative findings included a CSF leak at the time of surgery in 3 patients. One patient contracted bacterial meningitis 7 months postimplantation that was thought to be secondary to acute otitis media in the unoperated ear. Bilateral CSF leaks were noted in the middle ear by a lumbar puncture radionuclide and fluorescein dye study. Successful repair of the CSF leaks and reimplantation of the cochlear implant was carried out in this patient. Mapping and programming of the implant was found to be challenging in each of these patients. All patients demonstrated improved performance after implantation. Two patients demonstrated some open-set speech perception. One patient demonstrates improved use of temporal cues in a structured closed set. One patient has achieved no significant speech recognition at this time, but does have improved sound detection and awareness. Cochlear implantation in children with congenital inner ear abnormalities can be a successful method of rehabilitation. It should be recognized that the postoperative speech perception results may be highly variable among patients, and that intraoperative complications may occur.

Cerebrospinal Fluid Otorrhea↗
PubMed1990

Intraoperative blood salvage.

Interest in and use of IBS have increased recently. This form of haemotherapy involves the retrieval of blood shed perioperatively. IBS, together with other forms of ABT, has gained a prominent role in transfusion medicine, largely due to an increased awareness of the risks associated with transfusion of homologous blood. In addition to conserving erythrocytes, IBS prevents disease transmission, other adverse transfusion reactions, and alloimmunization to antigens in blood cells and plasma which may result from homologous blood use. An array of IBS devices is presently available, ranging from disposable canisters to complete processing systems. The devices are capable of recovering, filtering, washing and reinfusing shed erythrocytes. They can be divided into slow-flow and rapid-flow systems based on the rapidity of blood processing. Most systems use a dual channel aspiration cannula through which shed blood is aspirated and mixed with anticoagulant solution. The salvage procedure requires operator control at every step, even for the highly automated instruments. Various health care personnel have been trained to operate IBS equipment; a transfusion service nurse with blood bank expertise has proved to be a highly reliable operator in our practice. Extensive clinical observation has shown that salvaged erythrocytes function and survive normally. IBS has been applied in many surgical fields; it has two relative contraindications: its use in areas affected by infection or malignancy. Operative procedures characterized by large blood losses provide a cost-efficient application of IBS, including cardiac surgery, orthopaedic procedures, trauma, vascular surgery, and liver transplantation. New, highly efficient technology is emerging that is capable of recovering other blood components. Consequently, what presently amounts to erythrocyte recovery will be expanded shortly to include platelets and plasma, with its many constituents.

Blood Transfusion, Autologous↗
PubMed2001

Femoropopliteal bypass is not a generic procedure: a survey of the practice patterns of the Florida Vascular Society.

The purpose of this study was to evaluate whether surgeons perform femoropopliteal bypass using standard or dissimilar methods. A questionnaire was mailed to all members of the Florida Vascular Society, which consists of 83 board-certified vascular surgeons. Fifty-three responded (62%). Eighty-one questions covered aspects of the intraoperative and postoperative technical details usually involved in performing femoropopliteal bypass. Surgeons performed between 10 and 80 (mean 38) femoropopliteal bypasses per year. Only seven (13%) surgeons were aware of their patency rates. The results of this study showed that surgeons are largely unaware of their patency rates. When the variables used in this study were considered, no two surgeons performed the procedure in an identical manner. This variation in practice pattern may account for the discrepancy in reported patency rates for femoropopliteal bypass.

Angiography↗
PubMed2003

Bispectral index, serum drug concentrations and emergence associated with individually adjusted target-controlled infusions of remifentanil and propofol for laparoscopic surgery.

BACKGROUND: Target-controlled infusions (TCI) are used to simplify administration and increase precision of i.v. drugs during general anaesthesia. However, there is a limited relationship between preset targets and measured concentrations of drugs and between measured concentrations and measures of brain function, such as the bispectral index (BIS). METHODS: We set out to evaluate the performance of TCI devices for propofol (Diprifusor) and remifentanil (Remifusor, prototype), during laparoscopic cholecystectomy in 21 patients. We also checked if there was any correlation between serum concentrations of propofol and BIS during individually adjusted anaesthesia. RESULTS: The Diprifusor and Remifusor had a median absolute performance error of 60% and 25% respectively. Propofol concentrations were underpredicted by a median of 60%, and remifentanil concentrations were slightly overpredicted by a median of 7%. When anaesthesia was adjusted to keep BIS values between 45 and 60, no correlation existed between measured concentrations of propofol and the corresponding BIS values, although both BIS and serum propofol concentration discriminated well between the awake and asleep states. Emergence was rapid and uneventful in all patients. Female patients had a more rapid emergence than male patients (6.6 and 11.6 min respectively). CONCLUSIONS: TCI devices for remifentanil and propofol result in large variation in measured serum concentrations. The lack of correlation between BIS and serum concentrations of propofol adds to the debate about whether BIS measures hypnosis as a graded state during surgery. This study confirms that women wake up faster than men, but provides no explanation for this repeatedly shown difference.

Adult↗
PubMed2004

Spectral entropy measurement of patient responsiveness during propofol and remifentanil. A comparison with the bispectral index.

BACKGROUND: We compared two spectral entropies, state entropy (SE) and response entropy (RE), based on the irregularity of the EEG, to measure loss of response to verbal command (LOR(verbal)) and noxious stimulus (LOR(noxious)) with the bispectral index (BIS) during propofol infusion with and without remifentanil. METHODS: Three groups of 20 patients received an effect-site controlled propofol infusion (Ce(PROP)) starting at 1 microg ml(-1) and increased in steps of 0.5 microg ml(-1) at 4 min intervals. In addition, a remifentanil infusion was maintained at a group-dependent, fixed effect-site target concentration (Ce(REMI)) (0, 2 or 4 ng ml(-1)). The ability of BIS, SE or RE to predict LOR(verbal) and LOR(noxious) were compared with the changes in BIS, SE and RE using logistic regression, prediction probability (P(K)), and sensitivity/specificity. RESULTS: In all groups, BIS, SE and RE decreased with increasing Ce(PROP). However, BIS decreased more smoothly than SE and RE at deeper levels of sedation. At LOR(verbal), BIS(50), SE(50) and RE(50) increased with increasing Ce(REMI). BIS, SE and RE all detected LOR(verbal) accurately but BIS performed better at 100% sensitivity. Sensitivity/specificity for detection of LOR(verbal) decreased for all methods with increasing Ce(REMI). LOR(noxious) was poorly described by all measures. CONCLUSION: LOR(verbal) was detected accurately by BIS, SE and RE except for 100% sensitivity, where BIS performed better. Though BIS, SE and RE were influenced by remifentanil during propofol administration, their ability to detect LOR(verbal) remained accurate. None of the measures predicted LOR(noxious).

Acoustic Stimulation↗
PubMed2003

Awareness: Monitoring versus remembering what happened.

BACKGROUND: Awareness during anesthesia is foremost assessed with postoperative interviews, which may underestimate its incidence. On-line monitors such as the Bispectral Index and patient response to verbal command are not necessarily commonly used. This study investigated response to command during deep sedation (Bispectral Index 60-70) and the ability of prevailing monitoring techniques to indicate awareness and predict recall. METHODS: The authors systematically assessed the response to command using the isolated forearm technique while monitoring electroencephalographic and hemodynamic variables. Fifty-six elective surgical patients were repeatedly given verbal instructions to squeeze the observer's hand during target-controlled infusion with propofol and alfentanil. After recovery, conscious recall was assessed with a short structured interview. RESULTS: Overall, 1,082 commands were given. No response was observed to 887 (82%) commands, an equivocal response was observed to 56 (5%) commands, and an unequivocal response was observed to 139 (13%) commands. Of the 37 patients (66%) with an unequivocal response to command ("awareness"), nine (25%) reported conscious recall after recovery. Their reports provided valuable insights as to how awareness may be adequately addressed. Hemodynamic variables poorly predicted awareness, whereas parameters derived from the encephalogram, especially the Bispectral Index, were highly significant predictors (P < 0.0001). Electroencephalographic parameters did not discriminate between patients with or without conscious recall, whereas heart rate and responsiveness to command did. CONCLUSIONS: The incidence of awareness is underestimated when conscious recall is taken as evidence. Awareness can be monitored on-line with behavioral and modern neurophysiologic measures. Providing feedback during intra-anesthetic awareness helps patients to cope with a potentially stressful situation.

Adult↗
PubMedDate not supplied

Neurovascular complications of knee arthroscopy.

During the last 3 decades, arthroscopy has revolutionized the way knee surgery is performed. The indications and the applications of arthroscopic procedures in the knee joint have enormously increased with the improvement in surgical technique and advent of new arthroscopic equipment. The use of arthroscopic techniques has led to a significant decrease in morbidity for the patient with intraarticular abnormalities, in terms of both diagnosis and surgical correction. Even though knee arthroscopy is a minimally invasive procedure with relatively low morbidity, it is not without risk of complications, of which neurovascular complications are among the most serious and devastating. The reported incidence of neurovascular complication is low, but it may be underestimated. Many neurovascular complications that occur are preventable with a thorough understanding of neurovascular anatomy, good preoperative and intraoperative planning, and attention to the details of basic techniques and the equipment used for the procedure. It is imperative that the surgeon who is performing arthroscopy be aware of these neurovascular complications, recognize them as early as possible, and initiate further evaluation and treatment as expeditiously as possible. In this article, the causes, management, prevention, and medicolegal implications of neurovascular complications of knee arthroscopy are reviewed.

Animals↗
PubMed2004

BIS monitoring: awareness and catastrophic events.

The bispectral index is an electroencephalogram-based monitoring tool to help anesthesiologists determine depth of anesthesia. The bispectral index indicates both the potential for awareness and of relative hypnotic overdose, but it does not predict movement or hemodynamic responses to stimulation, and it cannot predict the exact moment consciousness returns. The bispectral index has been assessed for its relationship to awareness, and bispectral index monitoring appears to be generally associated with a low incidence of awareness. The bispectral index has also has been noted to detect periods of cerebral ischemia. It is also being used in intensive care units to help quantify the level of sedation in patients and as an outcome predictor in patients with brain injuries. Low values of the bispectral index often occur during catastrophic, ischemic, events but the use of this technology for the routine monitoring of such events is unproven.

Anesthesia, General↗