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Results for “Intraoperative Awareness”

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PubMed2000

Surgical risk factors in Larsen's syndrome.

The authors report on a child with typical Larsen's syndrome with some rare findings such as mixed-type hearing loss and with some potentially fatal operative risks including laryngomalacia and cervical instability. A few deaths with Larsen's syndrome have been reported associated with various fatal risks such as spinal instability. Therefore, laryngomalacia and several other potentially fatal risks are presented in this report as awareness may prove essential to orthopedic surgeons.

Abnormalities, Multiple↗

PubMed1992

Leg length discrepancy in total hip arthroplasty.

After conducting a thorough literature review, we realized that no consensus exists regarding the definition of a significant postoperative inequality. Whereas some investigators quantitate the disparity, accepting as much as 2.0 cm or in some cases less, others define a significant disparity as one that promotes adverse functional effects postoperatively. This lack of a consistent definition reflects the wide disparity of opinion regarding the problem of postoperative leg length inequalities in total hip surgery. Although the literature may lack consistency, it does reflect the collective experience of many surgeons and provides valuable insight when approaching the issue of limb lengths in reconstructive surgery of the hip. We offer the following suggestions: 1. Begin with a thorough history and physical examination. Question the patient as to whether he or she actually perceives a leg length inequality. 2. Be aware of apparent leg length discrepancies in patients with hip disease. The perceived limb shortening is usually the result of a fixed adduction contracture with little true shortening. 3. Develop a consistent approach of evaluation preoperatively, intraoperatively, and postoperatively. Employ reliable and convenient clinical measures and radiographic techniques. A method of intraoperative assessment is mandatory. 4. Redundancy in the system helps to minimize error. Good preoperative planning does not supplant the need for intraoperative assessment and vice versa. 5. Address the issue of offset in preoperative planning. Anticipate its misleading effects on intraoperative evaluation. 6. Mention potential inaccuracies regarding limb length reconstruction in total hip surgery as part of a routine preoperative evaluation. Patients' expectations should be high but temporized with realism.

Anthropometry↗

PubMed1995

Danger to the popliteal artery in high tibial osteotomy.

We report a case in which the popliteal artery was divided during upper tibial osteotomy performed with the knee in 90 degrees of flexion. This position is believed to allow it to fall safely back from the tibia, but we could find no published confirmation. We used duplex ultrasonography in ten healthy volunteers to measure the distance from the popliteal artery to the posterior surface of the tibia at various degrees of flexion of the knee. Our results showed that in 12 of 20 knees the popliteal artery was closer to the tibia in 90 degrees of knee flexion than in full extension. Surgeons performing upper tibial osteotomy should be aware that flexing the knee does not protect the popliteal artery from injury.

Aged↗

PubMed1991

Perioperative autotransfusion and its correlation to hemostasis and coagulopathies.

The use of autologous blood techniques affords the reduction or elimination of homologous blood transfusions for most patients. In addition, for certain religious faiths such as Jehovah's Witnesses or those patients with rare blood types, intraoperative salvage and return of the patient's own blood is the only source of available blood. Autologous blood salvage in the perioperative period includes: hemodilution; intraoperative salvage of lost blood; postoperative collection of shed blood. Perioperatively, autologous blood is salvaged and returned and the volumes involved do not create any hematological problems for the patient. In those cases involving large volumes of blood being processed and returned to the patient, the autotransfusionist must be aware of the possible alterations that may occur in the patient's coagulation system. The collection and reinfusion of wound drainage fluids from operative sites has the potential to cause severe bleeding problems. This paper will present an overview of autologous blood salvage techniques in the perioperative period along with a review of the clinical effects of autotransfusion on hemostasis. Also discussed will be possible coagulopathies that can be caused by returning collected autologous blood.

Blood Coagulation↗

PubMed2004

Hypertension, hypertensive heart disease and perioperative cardiac risk.

The evidence for an association between hypertensive disease, elevated admission arterial pressure, and perioperative cardiac outcome is reviewed. A systematic review and meta-analysis of 30 observational studies demonstrated an odds ratio for the association between hypertensive disease and perioperative cardiac outcomes of 1.35 (1.17-1.56). This association is statistically but not clinically significant. There is little evidence for an association between admission arterial pressures of less than 180 mm Hg systolic or 110 mm Hg diastolic and perioperative complications. The position is less clear in patients with admission arterial pressures above this level. Such patients are more prone to perioperative ischaemia, arrhythmias, and cardiovascular lability, but there is no clear evidence that deferring anaesthesia and surgery in such patients reduces perioperative risk. We recommend that anaesthesia and surgery should not be cancelled on the grounds of elevated preoperative arterial pressure. The intraoperative arterial pressure should be maintained within 20% of the best estimate of preoperative arterial pressure, especially in patients with markedly elevated preoperative pressures. As a result, attention should be paid to the presence of target organ damage, such as coronary artery disease, and this should be taken into account in preoperative risk evaluation. The anaesthetist should be aware of the potential errors in arterial pressure measurements and the impact of white coat hypertension on them. A number of measurements of arterial pressure, obtained by competent staff (ideally nursing staff), may be required to obtain an estimate of the "true" preoperative arterial pressure.

Anesthesia↗

PubMed2004

Intraoperative cutting errors in total knee arthroplasty.

INTRODUCTION: Precise reconstruction of leg alignment offers the best opportunity for achieving good long-term results in total knee arthroplasty (TKA). It was the aim of this study to evaluate the bone-cutting process as a potential source of inaccuracy in TKA. MATERIALS AND METHODS: In a consecutive series of 50 computer-assisted TKAs, cutting errors, which were defined as a difference between the cutting block position before sawing and the achieved resection plane afterwards, were measured for the distal femur and proximal tibia resection. Measurements were performed using a CT-based navigation system. RESULTS: For the distal femoral cut, there was a mean varus/valgus deviation of 0.6 degrees (SD+/-0.5 degrees ) and a mean flexion/extension deviation of 1.4 degrees (SD+/-1.3 degrees ). For the proximal tibia, varus/valgus alignment showed a mean deviation of 0.5 degrees (SD+/-0.5 degrees ). The mean sagittal variability was 1.0 degrees (SD+/-0.9 degrees ). Differences between the frontal and the sagittal plane were significant. CONCLUSION: To minimize cutting errors, techniques and instruments are needed which enable a more stable fixation of the cutting blocks or even more appropriate preparation instruments. Using a computer-assisted technique, the surgeon is aware of cutting errors occurring at each point of the operation and will therefore be able to correct these errors during surgery, while he is not aware of those errors with the conventional TKA technique.

Adult↗

PubMed1998

Early and late risk factors in surgical treatment of acute type A aortic dissection.

BACKGROUND: Morbidity and mortality of emergency repair of type A dissecting aneurysms of the aorta are high. This is an attempt to investigate the risk determinants of early and late results. METHODS: A series of preoperative and operative variables were retrospectively collected from the clinical records of 291 patients operated on between January 1, 1979, and December 31, 1995. Risk factors for surgical death were investigated with univariate analysis and stepwise logistic regression. Follow-up was conducted between December 1995 and February 1996. Analysis of late results was conducted by means of actuarial survival curves (life method). After removing the surgical deaths, risk factors for late deaths were analyzed by a Cox model. RESULTS: The in-hospital mortality rate was 36.1%. Significant independent determinants of operative or early death were preoperative shock, preoperative neurologic impairment, operation before 1986, perioperative bleeding, and prolonged clamping time. The 10-year survival rate was 36.9% +/- 4.4%. Twenty-six patients required repeat operation. The long-term prognosis was significantly worse in patients who needed reoperation. CONCLUSIONS: Growing awareness of this disease and quicker diagnosis have increased the number of patients with acute dissection of the ascending aorta who are taken early to operation. This new challenge must be met by better preoperative support and intraoperative monitoring, and by surgical techniques that focus on lowering the rate of late complications, for which lifelong follow-up must be provided.

Adult↗

PubMed1992

Left-sided superior vena cava: a not-so-unusual vascular anomaly discovered during central venous and pulmonary artery catheterization.

OBJECTIVE: To report our ICU experience with patients noted to have a left-sided superior vena cava after central venous and pulmonary artery catheterization. DESIGN: Retrospective review. SETTING: Surgical ICUs in a University and Veterans Administration Medical Center. PATIENTS: Five patients who had insertion of central venous or pulmonary artery catheters were noted to have abnormal placement. RESULTS: Five patients were noted to have a left-sided superior vena cava that was not appreciated on preinsertion radiography after central venous (two patients) or pulmonary artery catheterization (three patients). The finding of left-sided superior vena cava was confirmed by computed tomography scan (one patient), transesophageal echocardiography (one patient), bolus contrast injection (two patients), and intraoperative inspection (one patient). CONCLUSIONS: Left-sided superior vena cava occurs infrequently, most often in association with a right-sided superior vena cava. It is often associated with cardiac septal defects. The intensivist should be aware of its occurrence in order to not mistake catheters placed in it as being present in the arterial circulation or malpositioned outside of the venous circulation.

Adult↗

PubMed1980

Local anesthesia: serious consideration for extracranial carotid artery surgery.

Local anesthesia for extracranial carotid artery surgery presents an alternative to the methods currently used today. It does eliminate the necessity for complicated and expensive monitoring equipment. It has the advantage that both the surgeon and the anesthesiologist are aware at all times of the level of cerebral activity of the patient. The advantages and disadvantages of this technique are discussed. From an academic viewpoint, it gives the surgeon the ability to exactly determine in his intraoperative complications those cases in which cerebral infarction is due to embolization and those which could occur from inadequate collateral circulation.

Aged↗

PubMed2003

Management of inflammatory tracheoesophageal adhesions during transhiatal esophagectomy.

PURPOSE: Mediastinal adhesions, caused by the transerosal spread of disease, inflammatory diseases, or preoperative chemoradiotherapy, can result in diffi-culties and major complications during transhiatal esophagectomy (THE). However, few studies have specifically addressed the incidence and management of inflammatory adhesions encountered during THE. METHODS: We retrospectively analyzed the operative details and postoperative outcome of 70 patients who underwent THE between 1998 and 2000. Patients with inflammatory tracheoesophageal adhesions were identified and their operative records were reviewed for operative findings, intraoperative management, morbidity, and mortality. Patients with upper thoracic esophageal tumors and direct tumor spread to the airways were excluded from the analysis. RESULTS: Eight (11.4%) of the 70 patients had inflammatory adhesions and esophagectomy was possible in 7 of these 8 patients. Due to poor pulmonary status, one patient required conversion to the trnsthoracic approach, but the other six were managed transhiatally. Three patients underwent subtotal esophagectomy, the esophagectomy was completed by the inversion extraction technique in two, one required extended transhiatal dissection, and esophagectomy could not be completed in one due to dense inseparable adhesions between the trachea and esophagus. There was no major airway injury or bleeding. CONCLUSIONS: Inflammatory tracheoesophageal adhesions may be encountered in patients undergoing THE in developing countries. Thus, an awareness of the possibility of these adhesions and suitable modifications of the operating procedures are necessary to prevent major complications.

Adult↗

PubMedDate not supplied

The inferior non recurrent laryngeal nerve: a major surgical risk during thyroidectomy.

It is now widely established that systematic intraoperative location and diligent dissection of the recurrent inferior laryngeal nerve during thyroidectomy are the keystones to assure its anatomic and functional preservation. The possibility of abnormal routes, like a non-recurrent cervical course of the inferior laryngeal nerve is an additional major argument for its systematic identification to avoid surgical damage. In 2517 cervicotomies performed between 1992 and 1997 for at least right thyroid lobe excision or parathyroid glands exploration, 20 cases of non recurrent laryngeal nerve were identified (0.79%). The embryological nature of such a nervous anatomical variation results originally from a vascular disorder, named arteria lusoria in which the fourth right aortic arch is abnormally absorbed, being therefore unable to drag the right recurrent laryngeal nerve down when the heart descends and the neck elongates during embryonic development. The surgeon must be aware of the possibility of a non recurrent laryngeal nerve, which arises directly from the cervical vagus and therefore represents a severe potential pitfall during thyroidectomy. Given the absence of reliable clinical symptoms and signs or investigations indicating preoperatively the possibility of a non recurrent nerve, guidelines are given to prevent intraoperatively this major surgical risk.

Aorta↗

PubMed2005

Intraoperative positioning nerve injuries.

Intraoperative positioning nerve injuries are regrettable complications of surgery thought to arise from stretch and/or compression of vulnerable peripheral nerves. Generally thought to be preventable, these injuries still occur in patients despite rigorous preventative measures. Sometimes injuries, initially thought to be due to malpositioning, are caused by other factors, such as retraction injury or brachial plexitis. Because of the diversity of nerves susceptible to positioning injury, the clinician must be aware of a variety of presentations and must be able to distinguish them from other postoperative complaints. Prevention remains the mainstay of the management of positioning injuries. Diagnosed and managed appropriately, these lesions typically improve completely over time.

Anesthesia, General↗

PubMed1995

Anesthetic considerations in porphyrias.

Four hereditary types of porphyria are now classified as acute porphyrias. Enzymatic defects result in accumulation of porphyrin precursors (usually ALA and PGB). The quantity of these precursors may be normal or slightly increased in latent periods but increase to toxic levels during a porphyric crisis. Iatrogenic induction of ALA synthetase by administration of certain triggers (classically barbiturates) is only one of several factors which contribute to porphyric crisis. Signs and symptoms of acute porphyric attack consist primarily of neurologic dysfunction, which occurs secondary to neurotoxicity of ALA or diminished intraneuronal heme levels. Appropriate anesthetic management of porphyria requires knowledge of the type of porphyria (acute vs non-acute), assessment of latent versus active (crisis) phase, awareness of clinical features of porphyric attack, and knowledge of safe pharmacologic intervention.

Acute Disease↗

PubMed2005

Crisis management during anaesthesia: awareness and anaesthesia.

BACKGROUND: Patient awareness during general anaesthesia has considerable potential for severe emotional distress in the patient as well as professional, personal, and financial consequences for the anaesthetist. OBJECTIVES: To examine the role of a previously described core algorithm "COVER ABCD-A SWIFT CHECK", supplemented by a specific sub-algorithm for awareness, in the detection and management of potential awareness in association with general anaesthesia. METHOD: The potential performance of this structured approach for each of the relevant incidents among the first 4000 reported to the Australian Incident Monitoring Study (AIMS) was compared with the actual management as reported by the anaesthetists involved. RESULTS: Of the first 4000 reports received by AIMS, there were 21 incidents of patient awareness under general anaesthesia, and 20 of patients being paralysed while awake from "syringe swaps" before induction of anaesthesia. In 12 of the 21 reports there was an obvious cause, most commonly a low concentration of volatile agent (8 of 12 reports). The AIMS "core" crisis management algorithm would have detected the cause of awareness in all of these cases. In nine reports the course of anaesthesia appeared unremarkable, and in these the algorithm would not have been expected to detect or prevent awareness. Volatile agent monitoring would have prevented some cases of awareness, as would bispectral index electroencephalographic (BIS) monitoring. The role of BIS monitoring is still contentious, but it should be considered for high risk patients. CONCLUSION: Awareness should be minimised by thorough checking of equipment, particularly vaporisers, and frequent application of a structured scanning routine. Awareness may occur during crisis management and aftermath protocols should include patient follow up to detect and manage awareness when it occurs.

Algorithms↗

PubMed1999

Complications of retrograde balloon cautery endopyelotomy.

PURPOSE: Adult ureteropelvic junction obstruction is increasingly managed with endoscopic techniques. Retrograde balloon cautery endopyelotomy is quick, requires minimal hospital stay and allows most patients a rapid return to work. The complication rate of retrograde balloon cautery endopyelotomy ranges from 13 to 34%, with vascular injury in 0 to 16% of patients. We report 5 uncommon complications, including 4 vascular injuries, that clinicians should be familiar with when using this technique. MATERIALS AND METHODS: We reviewed 52 retrograde endoscopic endopyelotomy procedures performed during a 5-year period. There were 5 uncommon complications. RESULTS: Accessory lower pole renal artery injuries occurred in 3 patients, 1 of whom presented 12 days after endopyelotomy. Embolization was successfully performed in all 3 cases and none had subsequent hypertension. In 1 case a right ovarian vein laceration was not evident on preoperative or postoperative angiography. Emergency post-embolization abdominal exploration revealed a 2 mm. injury to the right ovarian vein before entering the right renal vein close to the ureteropelvic junction incision. Nephrectomy and ovarian vein ligature were curative. In 1 case the electrocautery wire broke intracorporeally after firing, resulting in a bobby pin-like configuration. Successful removal was accomplished by twisting the catheter and wrapping the wire around the tip, enabling atraumatic removal. CONCLUSIONS: Retrograde balloon cautery endopyelotomy is an emerging technology with potential adverse outcomes. The complications we noted are complex and potentially life threatening. Awareness of these complications may help avoid poor outcomes and expedite appropriate treatment.

Adolescent↗

PubMed1988

[The extra-hepatic bile ducts. Apropos of a new case of abnormalities].

A double anomaly of extrahepatic biliary pathways was detected in the same patient. The first anomaly involved the cystic duct, which emptied into the third part of duodenum, the second anomaly the common bile duct which was implanted into the right side of the cystic duct one centimeter from the papilla. An anomaly of this type has not been reported previously in the literature and surgeons should be aware of its possible occurrence.

Adult↗

PubMed2005

Immediate postoperative fluid retention and weight gain after shoulder arthroscopy.

PURPOSE: The primary purpose of this study was to determine the amount of weight gain immediately after shoulder arthroscopy. In addition, patient and surgical factors correlated with weight gain were analyzed. We hypothesized that there would be a significant increase in weight immediately after shoulder arthroscopy and that the amount of weight gain would correlate with a number of surgical factors. TYPE OF STUDY: Observational case series. METHODS: Fifty-three patients were enrolled in the study. There were 34 male and 19 female patients, with a mean age of 47.1 +/- 13.8 years. All patients were weighed before and after surgery using the same weight scale by the same observer. Weight gain was calculated and adjusted to account for the weight of the dressing and sling. Weight gain then was correlated to various clinical and surgical variables. Pearson correlation coefficients, Student t tests, and stepwise regression were used to determine significant correlations between clinical and surgical variables and weight gain. RESULTS: The mean amount of net weight gain was 8.7 +/- 3.9 lb (range, 0.8-18.8 lb), representing 4.6% +/- 2.1% of preoperative weight. The mean amount of weight gain attributable to arthroscopy fluid only was 4.2 +/- 3.8 lb (range, 0-14.5 lb), representing a gain of 2.2% +/- 2.0% of preoperative weight. The mean amount of intravenous fluid infused was 1,885 +/- 547 mL, and the mean amount of normal saline arthroscopy fluid used was 30 +/- 24 L. Surgical time, the amount of arthroscopy fluid, the size of the rotator cuff tear, the number of tendons involved, the presence of a subscapularis tear, the number of procedures performed, the concomitant performance of a subacromial decompression, the number of BioCorkscrew (Arthrex, Inc., Naples, FL) anchors used, and the total number of anchors used all correlated with increasing weight gain (all P < .05). A procedure of stepwise regression selection did not identify any quantitative parameters attributable to weight gain other than the earlier-described parameters. There were no significant intraoperative or postoperative complications attributable to the amount of weight gain. CONCLUSIONS: Weight gain immediately after shoulder arthroscopy is a common finding. Although no complications were seen in this group of patients, both patients and surgeons should be aware of this concern after shoulder arthroscopy and the potential complications related to it.

Adult↗

PubMed1997

Cardiac entrapment during minimally invasive aortic valve replacement.

Reduced exposure during minimally invasive valve operations poses new difficulties in intraoperative management. Transesophageal echocardiography improves intraoperative management. During a minimally invasive aortic valve replacement, we encountered unexpected hypotension due to mechanical compression of the right ventricle against the sternum. Transesophageal echocardiography facilitated rapid diagnosis of this problem. Surgeons performing these procedures should be aware of this potential problem.

Aortic Valve↗