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PubMed2005

Advanced patient monitoring displays: tools for continuous informing.

We reviewed the use of advanced display technologies for monitoring in anesthesia. Researchers are investigating displays that integrate information and that, in some cases, also deliver the results continuously to the anesthesiologist. Integrated visual displays reveal higher-order properties of patient state and speed in responding to events, but their benefits under an intensely timeshared load is unknown. Head-mounted displays seem to shorten the time to respond to changes, but their impact on peripheral awareness and attention is unknown. Continuous auditory displays extending pulse oximetry seem to shorten response times and improve the ability to timeshare other tasks, but their integration into the already noisy operative environment still needs to be tested. We reviewed the advantages and disadvantages of the three approaches, drawing on findings from other fields, such as aviation, to suggest outcomes where there are still no results for the anesthesia context. Proving that advanced patient monitoring displays improve patient outcomes is difficult, and a more realistic goal is probably to prove that such displays lead to better situational awareness, earlier responding, and less workload, all of which keep anesthesia practice away from the outer boundaries of safe operation.

Anesthesia↗

PubMedDate not supplied

Pseudo-renal failure following total abdominal hysterectomy.

Intraperitoneal urinary bladder perforation should be in the differential diagnosis of acute oliguric renal failure soon after gynecological surgery. We present a case of reversible acute pseudo-renal failure after total abdominal hysterectomy for uterine fibroid. Biochemical features of uremia occur as a result of intraperitoneal extravasation of urine, which is in turn reabsorbed through the peritoneum. Early recognition and surgical repair, as opposed to dialysis therapy, are warranted in such clinical setting. Nephrologists, who are often the first to encounter those patients with presumably acute renal failure, should be aware of this condition. Prompt recovery of the serum biochemistry is to be expected, in contradistinction to genuine renal failure or kidney insults.

Acute Kidney Injury↗

PubMed1997

Complications of shoulder arthroscopy.

Shoulder arthroscopy can be a safe and effective tool to perform a variety of diagnostic and therapeutic procedures about the shoulder. Careful attention to positioning, fluid management, use of traction, and appreciation of shoulder anatomy to select portal placement will help decrease the common complications associated with shoulder arthroscopy. The awareness of uncommon complications, such as deep venous thrombosis, pneumothorax, and iatrogenic rotator cuff tears will help the orthopedic surgeon to promptly diagnose and treat these problems.

Arthroscopy↗

PubMed2003

Morbidity of laparoscopic radical prostatectomy: summary of early multi-institutional experience in Japan.

AIM: Laparoscopic radical prostatectomy is being evaluated throughout the world. The aim of the present study is to report early multi-institutional experience of the procedure in Japan. METHODS: A total of 148 men who were diagnosed with clinically localized prostate cancer underwent laparoscopic radical prostatectomy at seven different institutions in Japan. Early complications (within 30 days postoperatively) and postoperative convalescence were reviewed retrospectively. The median age of patients was 68.0 years (range, 51-80). RESULTS: The median operative time was 403 minutes (range, 167-925; average, 427). Blood loss ranged from 50 to 5000 mL (median, 540; average, 856). A total of 66 complications were reported in 55 patients (37.2%). Intraoperative complications were noted in 25 of 148 patients (16.9%): 10 rectal injuries (6.8%); five bladder injuries (3.4%); five cases of subcutaneous emphysema (3.4%); two intestinal injuries (1.4%); one major vessel injury (0.7%); one ureteral injury (0.7%); and one obturator nerve injury (0.7%). Overall, 16 of 148 patients (10.8%) required open conversion or postoperative open surgical repair. The most common postoperative complications were anastomotic leakage (6.8%), wound-related complications (4.7%) and perineal pain (4.7%). The bladder catheter was removed on day 7 or earlier in 73 cases (49.3%). The median time to ambulation was 1 day (mean 1.4, range 1-5). Oral intake was started on postoperative day 1 in 67 patients (45.2%) and on postoperative day 2 in 65 (43.9%). CONCLUSION: Although laparoscopic radical prostatectomy is technically demanding, reduced blood loss and shorter convalescence periods can be expected from the procedure. Surgeons should be aware of the disturbingly high morbidity rate related to early experience. By mastering laparoscopic skills and sharing knowledge, surgeons could reduce the impact of the learning curve required to complete this procedure competently.

Aged↗

PubMed2001

Surgical complications after primary nephrectomy for Wilms' tumor: report from the National Wilms' Tumor Study Group.

BACKGROUND: Surgical complications are a recognized morbidity of the treatment of patients with Wilms tumor. This study examines the incidence of surgical complications in the most recently completed study from the National Wilms' Tumor Study Group (NWTSG). STUDY DESIGN: The fourth National Wilms' Tumor Study (NWTS-4) enrolled 3,335 patients from August 1986 to August 1994. A random sample of 534 patients was selected from 2,290 eligible patients randomized to treatment regimens or enrolled in the followed category and treated according to NWXTSG protocol. The patient records received at the NWTSG Data and Statistical Center were analyzed for surgical complications (intraoperative and postoperative). RESULTS: Sixty-eight patients (12.7%) experienced 76 complications. Intestinal obstruction was the most common complication (5.1% of patients), followed by extensive hemorrhage (1.9%), wound infection (1.9%), and vascular injury (1.5%). The incidence of surgical complications in NWTS-4 was significantly lower than NWTS-3 (12.7% versus 19.8%, p < 0.001). There has been a marked decrease in the risk of extensive intraoperative bleeding and major intraoperative complications. Factors previously shown to be associated with an increased risk for surgical complications, together with indicators of type of hospital and surgeon specialty, were analyzed by multiple logistic regression analysis. Intravascular extension into the inferior vena cava (IVC), the atrium, or both (p = 0.02; odds ratio [OR] 3.8, 95% confidence interval [CI] 1.2, 11.8), and nephrectomy performed through a flank or paramedian incision (p = 0.02; OR 5.3, 95% CI 1.3, 22) were both associated with increased risk of complications. Tumor diameter greater than or equal to 10cm was also associated with an increased risk of surgical complications (p = 0.05; OR 2.0, 95% CI 1.0, 3.9). The risk of complications was higher if the nephrectomy was performed by a general surgeon (OR 9.0, 95% CI 1.3, 65; p = 0.03) rather than a pediatric surgeon (reference group, OR 1.0) or pediatric urologist (OR 0.7, 95% CI 0.3, 1.8). CONCLUSIONS: The incidence of surgical complications in NWTSG patients undergoing primary nephrectomy has significantly decreased over the past decade. But surgical morbidity should not be overlooked. It is important that surgeons treating young children with solid tumors are aware of their role and the potential risks encountered in removal of the primary tumor. This study found that surgical specialists who primarily treat children can perform these operations with lower surgical morbidity.

Chemotherapy, Adjuvant↗

PubMed2003

Spontaneous uterine rupture with amniotic sac protrusion at 28 weeks subsequent to previous hysteroscopic metroplasty.

BACKGROUND: Hysteroscopic metroplasty improves pregnancy outcome in case of uterine septum. Uterine rupture during a pregnancy following this procedure may occur. CASE: A patient with a history of hysteroscopic resection of a uterine septum complicated by fundal perforation, presented at 28 weeks a spontaneous uterine rupture with amniotic sac protrusion through the uterine wall disruption. CONCLUSION: Uterine rupture during pregnancy following a hysteroscopic metroplasty may occur even though it appears to be a very uncommon event. Patients who have had this procedure should be aware of this potential risk in case of future pregnancies. How to avoid such complication is still unclear.

Adult↗

PubMed2001

[Difficult ventilation during induction of anesthesia in a patient with Arnold-Chiari malformation type II].

Arnold-Chiari malformation is a congenital disorder with caudal displacement of the cerebellar tonsils through the foramen magnum into the cervical canal. We report difficulty with ventilation during the induction of anesthesia due to apnea and laryngospasm in a 5-year-old female with Arnold-Chiari malformation type II diagnosed at birth. She had had short periods of apnea during infancy, but was asymptomatic recently. Slow induction of anesthesia was performed using sevoflurane, but just after induction, the patient developed apnea and we could not ventilate her due to laryngospasm. We woke her up, and induced anesthesia with barbiturates. The operation was performed without complications, but she had another apnea attack with laryngospasm at extubation. This case suggests that it is important to be aware of the possibility of apnea due to disorder of the respiratory center in patients with Arnold-Chiari deformity.

Anesthesia, Inhalation↗

PubMed1998

The history and achievements of the National Confidential Enquiry into Perioperative Deaths.

The National Confidential Enquiry into Perioperative Deaths started in 1989 as a direct development of a Confidential Enquiry in the United Kingdom in 1984. Different samples from the 20,000 deaths in hospital within 30 days of a surgical operation are selected each year. Questionnaires about these are examined by groups of anaesthetists and surgeons, and lessons about the quality of perioperative care are derived. Causation is not emphasized but examples of potential for improvement are sought. Changes of consultant practice, increase in medical audit, improvement in physiological monitoring, appropriate matching of specialist experience to patients' medical conditions and increased awareness of the need for critical care areas are believed to have been influenced by this unique enquiry.

Adolescent↗

PubMed1995

[Open surgical therapy of the rotator cuff].

Almost 100 years have passed since the first report of rotator cuff repair in 1898 by W. Müller. Even now new operative techniques are being developed. Various solutions for difficult extended forms of rotator cuff lesions are available besides the closed and semi-closed arthroscopic techniques. Anatomical reconstructive procedures such as local or distant tendon transfer compete with extra-anatomical procedures such as simple debridement, equatorial partial reconstruction or replacement with a delta flap. Hemiarthroplasty of the shoulder has proven to be more and more the treatment of choice in cases of inoperable rotator cuff defects with painful arthropathy. The euphoria caused by complicated reconstructive methods for massive tears has subsided due to an awareness that loss of function is inevitable in chronic degenerative tears with muscle atrophy. Reconstruction should be coordinated step by step with the operative procedure as well as adapted to the biological situation. It should definitely not be forced at any price using an algorithm for a rotator cuff tear operation, the best operative method must be selected by clinical, radiological and intraoperative criteria. The situation is completely different for an acute traumatic rotator cuff tear. Every effort should be made to perform early anatomic reconstruction in a young patient, as the function of the rotator cuff is of great importance in the working world. In contrast to degenerative changes of the rotator cuff tendon, large ruptures can be treated successfully if early immediate repair is performed. The long head of the biceps tendon plays a special role in combination with a rotator cuff tear. The concomitant lesions of the long head of biceps should not to be over-looked when repairing the rotator cuff tear. Until now, a special form of rotator cuff pathology has not received much attention--the so-called interval lesion. It is the forerunner of the rotator cuff tear. The interval lesion is a partial tear of the ligamentous structures between the supraspinatus and subscapularis tendon and leads to damage of the long head of the biceps. The interval lesion can only be diagnosed by arthroscopy or open exploration of the rotator interval.

Age Factors↗

PubMed1993

Gallbladder cancer discovered during laparoscopic surgery. Potential for iatrogenic tumor dissemination.

OBJECTIVE: To examine the results of treatment of laparoscopically discovered gallbladder cancer. DESIGN: Retrospective review of clinical data for the 10 patients with laparoscopically discovered gallbladder cancer who were referred to our institution for definitive surgical therapy. SETTING: An oncologic referral center. PATIENTS: All patients in the 24-month period from November 1990 to November 1992 with this entity who were referred for surgical therapy. INTERVENTION: Exploratory laparotomy was performed on all patients. Resection with curative intent was performed when possible. MAIN OUTCOME MEASURES: Resectability and outcome of cancer treatment. RESULTS: In three patients, a subsequent radical resection was performed and as a result, two patients are currently free of disease. Intraperitoneal spread, not present at the original laparoscopy and associated with violation of tumor at laparoscopy, precluded potentially curative resection for four patients. In two of these patients, there was obvious tumor growth within the laparoscopy tracts. CONCLUSIONS: Tumor dissemination is a real hazard of laparoscopic violation of gallbladder integrity in the presence of gallbladder cancer. Modification of management based on awareness of such a hazard is needed to improve resectability and outcome of future cases of laparoscopically discovered gallbladder cancer.

Aged↗

PubMedDate not supplied

Time-frequency spectral representation of the EEG as an aid in the detection of depth of anesthesia.

A time-frequency spectral representation (TFSR) has been used to study the nonstationary information in the EEG as an aid in determining the anesthetic depth. This paper uses a TFSR with an exponential weighting function for the purpose. Raw EEG data were collected form 10 mongrel dogs at various levels of halothane anesthesia. Depth of anesthesia was tested by observing the response to tail clamping, which is considered a supramaximal stimulus in dogs. A positive response was graded as awake (depth 0), and a negative response was graded as asleep (depth 1). The EEG obtained during a period of 30 sec tail clamp was processed into TFSRs. It was observed that at depth 0, the spectrum becomes localized in time and frequency. The percentage of energy in the delta (1-3.5 Hz) and theta (3.5-7.5 Hz) frequency bands increased. At depth 1, the spectrum remained unchanged throughout the period of tail clamp. The performance of the TFSR in detecting the patient's awareness was also compared with the power spectrum. It was concluded that under certain anesthetic conditions, the TFSR is superior to the power spectrum.

Anesthesia↗

PubMed2002

[Relaxation and the electromyographic identification of the recurrent laryngeal nerve].

INTRODUCTION: Electromyography for the identification of the recurrent laryngeal nerve is gaining ever more acceptance in thyroid surgery. Relaxation of the patient, e.g., to improve intubation conditions for anesthesia, carries a potential risk for error. METHOD: After definite identification of the recurrent laryngeal nerve and the vagus nerve (Neurosign 100, Magstim Co., Wales), ten consecutive patients were relaxed with mivacurium and atracurium besylate at a weight-dependent ED95 dosage. After peripheral relaxation was achieved (TOF-Watch, Organon Teknika Corp., at the adductor muscle of the thumb), the signal derived via the vocal muscle was assessed acoustically in 3-min intervals by the surgeon and graphically recorded by computer (EWACS, Inomed Co.). RESULTS: Complete peripheral relaxation was attained with mivacurium after 3-7 min and with atracurium after 7-11 min. A decrease in amplitude of the vocal muscle signal of >60% was recognized by the surgeon as a weakened signal and could be confirmed during an average duration of 13.3 min with mivacurium (maximum: 37 min) and 17.7 min with atracurium besylate (maximum: 23 min), respectively. Complete obliteration of the acoustic signal (<20% of the initial signal) occurred in three of six patients treated with mivacurium and in four of four patients treated with atracurium. CONCLUSIONS: The accuracy of electromyography of the recurrent laryngeal nerve can be substantially impaired by the administration of relaxants. If this medication cannot be dispensed with, the surgeon must be aware of the situation. In these cases, a peripheral relaxometer should also be employed to monitor relaxation as it subsides.

Adult↗

PubMed2001

Cervical subcutaneous emphysema: an unusual complication of adenotonsillectomy.

Removal of the tonsils and adenoid tissue because of recurrent infection and/or respiratory obstruction is one of the most commonly performed operations. A rare complication during this intervention is subcutaneous surgical emphysema. The awareness of anaesthesiologists and otolaryngological surgeons will protect the patient from serious consequences. We report our experience with this complication and provide a review of the literature.

Adenoidectomy↗

PubMed2001

Abnormal implantation of permanent pacemaker lead in the left ventricle via a patent foramen ovale: clinical and echocardiographic recognition of a rare complication.

An 84-year-old man with a history of permanent pacemaker placement had a preoperative cardiac evaluation for prostate cancer surgery. The patient was asymptomatic, and the results of a physical examination were consistent with a right bundle branch block, which was confirmed by electro-cardiogram as his paced rhythm. A chest radiograph raised the possibility of an abnormal lead location, and transthoracic echocardiography confirmed the mechanism of an abnormal placement of the pacemaker lead. Left ventricular location of pacemaker is rare, and awareness of its clinical and imaging findings, complications, and management options is important for clinicians involved in the care of patients with pacemakers.

Aged↗

PubMed2004

Eyelid sebaceous carcinoma masquerading as in situ squamous cell carcinoma.

BACKGROUND: Sebaceous carcinoma (SC) accounts for 1% to 5.5% of all eyelid malignancies. Diagnosis is often delayed because of its ability to masquerade as other periocular lesions both clinically and histologically. OBJECTIVE: To promote a high index of suspicion among Mohs surgeons for SC when managing biopsy-proven in situ squamous cell carcinoma (SCC) of the eyelid, particularly the upper eyelid. METHODS: This is a retrospective case review. RESULTS: A 77-year-old woman and a 71-year-old man were referred for Mohs micrographic surgery with a diagnosis of upper eyelid in situ SCC on biopsy. Intraoperatively, the presence of clear cell differentiation, in addition to extensive conjunctival involvement, leads to the correct diagnosis of SC. One case was subsequently found to have Muir Torre syndrome. CONCLUSION: Early diagnosis of eyelid SC leads to a better outcome and a higher survival rate. Hence, when managing in situ SCC of the eyelids, particularly the upper eyelid, Mohs surgeons should be aware of the possibility of SC and actively look for sebaceous cell differentiation or extensive conjunctival spread.

Adenocarcinoma, Sebaceous↗

PubMed1993

Sudden cardiac arrest during adenotonsillectomy in a patient with subclinical Duchenne's muscular dystrophy.

We describe a four-year-old boy of Indian descent who had elective adenotonsillectomy for chronic sore throat and partial airway obstruction. About 10 minutes into the procedure, the patient suddenly developed cardiac asystole. After prolonged cardiac resuscitation, recovery was achieved. No permanent neurologic deficits resulted. The child was later found to have a strong family history of Duchenne's muscular dystrophy (DMD) and an elevated serum creatine kinase level documented since shortly after birth. We reviewed several case reports substantiating the risk for cardiac arrest during general anesthesia in DMD patients, and we concluded that DMD is a little-known risk for cardiac arrest during general anesthesia. The otolaryngologist must be aware of this potential complication, because tonsillectomy and adenoidectomy are commonly indicated for children at an age when DMD may be subclinical.

Adenoidectomy↗

PubMed2004

Extensive peritoneal and omental lymphomatosis with raised CA 125 mimicking carcinomatosis: CT and intraoperative findings.

Diffuse peritoneal and omental seeding are well-known forms of dissemination of metastatic carcinoma. A wide variety of primary neoplasms may cause peritoneal and omental carcinomatosis, most commonly carcinomas of the ovary, gastrointestinal tract and breast. Extensive involvement of the peritoneal cavity with lymphoma is, however, rare. The association of peritoneal lymphoma with a raised CA 125, a tumour marker which is commonly raised in ovarian carcinoma, is a highly challenging clinical situation, which to our knowledge has not been published before in the medical literature. Not being aware of the possibility of this unusual combination of clinical, laboratory and imaging findings can lead to an erroneous diagnosis, as in our case.

Adult↗

PubMed1998

[Salmonella enteritidis infected false aneurysm of the superficial femoral artery in an HIV seropositive patient].

In the course of an infection with human immunodeficiency virus, a large variety of complications affecting all organ systems can occur. However, complications affecting the vascular system demanding surgical intervention are rare. In the case presented we report a 67-year-old HIV-seropositive patient who underwent surgery for a huge abscess in the thigh. Intraoperatively unexpectedly we found a mycotic aneurysm of the femoral superficial artery and the causactive bacterium proved to be Salmonella enteritidis. Because of the rising number of HIV-infected patients we suspect that the amount of complications involving the vascular system and demanding surgical intervention will also increase. Therefore, when diagnosing and deciding on therapy for patients with AIDS, the physician must be aware that vascular complications due as a result of HIV infection might occur more frequently in the future.

AIDS-Related Opportunistic Infections↗