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PubMedDate not supplied

[An anesthetized anesthesiologist tells his experience of waking up accidentally during the operation].

We report the recollections of an anaesthesiologist who experienced urogenital surgery under balanced anaesthesia which was insufficient to prevent awareness during a part of the procedure. The patient was hard apprehensive before surgery and neither sedative nor amnesic drugs were done as premedication. He received an Innovar, thiopentone, suxamethonium, nitrous oxide/oxygen sequence for intubation. Awareness occurred not long after but before administration of isoflurane for maintenance. In that terrifying moments the patient was conscious without pain. According to him the worst aspect of the experience was desperately wanting to move or speak and being unable to do so. In the event of unexpected awareness, the anaesthesiologist must deal with the patient in an honest and forthright manner. Failure to do so lead to dire psychological consequences for the patient and expensive malpractice litigation for the anaesthesiologist.

Adult↗

PubMedDate not supplied

[Vascular intracranial procedures in Jehovah's Witnesses. Erythropoietin in the preparation for the surgery].

Intraoperative haemorrhage or major bleeding may still cause serious problem in present-day neurosurgery, especially with reference to major vascular procedures despite the improving surgical techniques and methods of performing bloodless procedures. This is why certain neurosurgical procedures are not attempted without prior preparation of a major amount of blood. Jehovah's Witnesses refuse their consent to be subjected to blood transfusion of their own or foreign blood despite their full awareness of a potential danger to their lives. This paper describes three patients subjected to the major vascular intracranial procedures (two cases of clipping intracranial aneurysms, and one case of removal of arteriovenous intracranial angioma in anaemic patient), and one case of endovascular neuroradiosurgical procedure in intracranial aneurysm. This last method is presented as alternative procedure to decrease complications that are related to bloodless interventions suggest certain management methods which may decrease the surgical risk. One of those methods erythropoietin in treatment of postoperative anaemia and in preparing anaemic patients to vascular intracranial procedures.

Anemia↗

PubMed1998

Central nervous system monitoring during open heart surgery: an update.

Electroencephalography (EEG) is used to monitor the function of the central nervous system in a variety of surgical procedures. During cardiac surgery with cardiopulmonary bypass, ischemic changes on the EEG as a result of impaired central nervous system blood supply can be noted. The EEG also may be used to monitor the functional state of the brain during and after profound hypothermic circulatory arrest. If a desired goal is to reduce cerebral metabolism using a barbiturate or other such agent, the EEG can be monitored to provide a measurable pharmacodynamic end point (burst suppression). Techniques have been developed to process the EEG signal using a computer and to improve on-line interpretation. These include fast Fourier transformation to develop a three-dimensional plot or compressed spectral array, evoked-potential monitoring, and bispectral analysis to derive a univariate descriptor of the EEG. These techniques have been used to detect awareness and indirect memory function, as well as to assess the adequacy of anesthesia. There is a good correlation between implicit memory and alterations in midlatency auditory-evoked responses. The bispectral index has been used to assess the adequacy of anesthesia as well as to detect awareness. Preliminary studies suggest that titrating the anesthetic to bispectral index levels may be useful during cardiac surgery.

Anesthetics, General↗

PubMed1988

Bone-ingrowth hip prostheses in asymptomatic patients: radiographic features.

The radiographic changes of 85 bone-ingrowth femoral prostheses in 77 asymptomatic patients were reviewed. The average postoperative follow-up time was 21.8 months. In decreasing order of frequency, the alterations included (a) remodeling of the proximal medial edge of the cut femoral neck (stress shielding) (98%), (b) linear lucency with a thin sclerotic margin at the prosthesis-bone interface (that may increase in width or length with time) (79%), (c) endosteal sclerosis at the prosthesis tip (36%), (d) heterotopic bone (24%), (e) cortical thickening at the tip of the prosthesis (12%), (f) prosthetic subsidence (7%), (g) intraoperative fracture (7%), and (h) periosteal reaction (4%). In this study, radiographic evidence of these findings was not associated with clinical failure. This is in distinction to the findings in cemented prostheses, in which many of these phenomena (especially the development of increasing width of the lucent line adjacent to the cement or prosthesis) have been associated with failure. Long-term investigations of porous-coated prostheses are necessary. Currently, however, an awareness of the radiographic alterations that occur with asymptomatic bone-ingrowth prostheses can prevent their misinterpretation as abnormal.

Female↗

PubMed1998

Lower extremity compartment syndrome resulting from a toddler's bed.

This report recounts an unusual case of compartment syndrome of the leg and foot resulting from hanging on the side of a toddler's bed in a 11/2-year-old boy. Parents apparently found the patient on the side of the bed in the morning. Presentation to hospital revealed obvious tense compartments of the leg and foot. Intraoperative pressures were >100 mm Hg. Complete fasciotomies with secondary closure and skin grafting were performed. An ankle-foot orthrosis was used to prevent progression of ankle equinus. Jobst pressure garments were used to prevent hypertrophic scarring. One-year follow-up showed normal gait, function, and joint range of motion. Social services were consulted and the US Consumer Product Safety Commission was notified. As pediatric physicians, we need to be aware of possible and potential hazards in the child's environment. This case represents a unique case of compartment syndrome related to persistent limb elevation and compression.

Beds↗

PubMed1997

Vernix caseosa: an unusual cause of post-cesarean section peritonitis.

Surgeons should be aware of a very unusual cause of post-cesarean section peritonitis. This rare form of peritonitis is caused by the spillage of vernix caseosa material into the peritoneal cavity. The exact mechanism of the development of peritonitis in these few cases is unknown. Clinically, vernix caseosa peritonitis should be considered in the post-cesarean section acute abdomen after excluding the more common causes of peritonitis such as appendicitis and perforated viscus. Intraoperatively, the presence of cheese-like yellow patches limited to the serosal layer of visceral organs is the most characteristic feature. Histopathological examination of these serosal patches reveal the desquamated anuclear squamous cells confirming the diagnosis. Postoperative treatment with antibiotics should be continued. The addition of steroids (only after confirming the diagnosis pathologically) has a significant effect on improving the clinical outcome.

Abdomen, Acute↗

PubMed2001

Bispectral index monitoring in children undergoing mild hypothermic cardiopulmonary bypass.

BACKGROUND: In this prospective, cohort study of 15 children (median age 7.7 years, range 4.9-16.5 years) undergoing atrial septal defect repair, we evaluated changes in the Bispectral index (BIS) as a potential monitor of level of consciousness during cardiac anaesthesia. METHODS: Identical cardiac surgery, cardiopulmonary bypass (CPB) and anaesthetic techniques were used, including mild hypothermia and an early extubation protocol. BIS, mean arterial pressure, heart rate and tympanic temperature were recorded at baseline postinduction (Tbaseline), skin incision (Tincis), sternotomy (Tsternot), aortic cannulation (Tcann), nadir temperature (Tnadir), rewarmed (Trewarmed), immediate post-CPB (TpostCPB), chest drain insertion (Tdrains), sternal wires (Twire), skin closure (Tclosed) and spontaneous movement (Tmove). As a measure of stress response, serum lactate, glucose, norepinephrine and epinephrine levels were measured at Tbaseline, Tsternot, Tcann, Tnadir, Trewarmed and Tdrains. Explicit memory testing was undertaken prior to hospital discharge. RESULTS: BIS increased significantly during the rewarming phase (Trewarmed versus Tbaseline and Tnadir, P<0.001). Lactate, epinephrine and glucose levels were also significantly elevated at Trewarmed. There were no correlations between BIS and the increase in epinephrine, lactate and glucose during rewarming, nor with changes in heart rate or mean arterial pressure during surgery. All patients had an uneventful recovery without evidence for explicit recall. CONCLUSIONS: The increase in BIS during the rewarming phase could reflect an increase in conscious level, and is consistent with the reported risk for awareness during this phase of cardiac surgery.

Adolescent↗

PubMedDate not supplied

Non-recurrent laryngeal nerve: identification during thyroid surgery.

The non-recurrent course of the inferior laryngeal nerve is a rare anomaly. The incidence varies from 0.3 to 4% on the right side. It is extremely rare on the left side. The awareness of such an anomaly is essential as the risk of damage to the nerve is higher during thyroid surgery. Two cases of non-recurrent laryngeal nerve are reported, and the embryology and method of identification are discussed.

Adult↗

PubMed1986

Occult spinal dysraphism. Case report and review of the literature.

This case report and review of the literature is presented to create a greater diagnostic awareness of occult spinal dysraphism. Early recognition is based upon an understanding of this congenital anomaly and its variable presentations. These most commonly include abnormal gait, various cutaneous manifestations, particularly subcutaneous lipomata, and less frequently urological complaints. Surgical intervention, to arrest disease progression, is the primary mode of treatment, and functional improvement is variable. Long-term prognosis is dependent upon severity of neurologic deficits prior to surgery and the type of lesion found intraoperatively. Familial occurrence has been reported and genetic counseling may be an important preventive measure. Recent radiologic investigations have been concerned with the use of ultrasonography in screening infants at risk.

Child↗

PubMed1989

[Complications during implantation of 3260 hip endoprostheses under spinal anesthesia].

There is a tendency to perform increasingly severe operations on patients of advanced age. Because geriatric patients are of greater risk when under anesthesia during operation, it is necessary to be aware of the possible anesthesia-related and operation-related complications. In a retrospective study the complication rate with regard to patients (age, multimorbidity), operation (e.g. number and duration of procedures) and anesthesia was analyzed. Of particular interest were the kind and degree of certain complications at a particular time. Directly following the induction of anesthesia and the second application of cement the complication rate depended on patient age and multimorbidity, but the intraoperative complication rate was closely related to the operation. Sensory spreading of spinal anesthesia was one of the anesthesiological factors leading to an increase in the complication rate. Cardiovascular complications occurred most frequently following the induction of spinal anesthesia (hypotension: 6.50%, tachycardias: 3.74%, bradycardias: 3.68%). The most serious circulatory complication--shock--however was primarily seen during surgery [1.80% (n = 59)]. Asystoles [0.27% (n = 9)] were only seen intraoperatively and after the second cement application. Pulmonary embolism [0.12% (n = 4)], respiratory arrest [0.09% (n = 3)] and exitus [0.64% (n = 21)] exclusively occurred following the second administration of cement. Geriatric patients are particularly at risk directly after induction of anesthesia and following application of the second cement. Thorough preoperative preparation (with regard to the cardiac and circulatory situation), spinal anesthesia of less than Th 6 and a rapid surgical procedure are necessary to reduce the morbidity and mortality.

Adult↗

PubMed1993

Prosol-chlorhexidine irrigation reduces the incidence of bacteremia during ultrasonic scaling with the Cavi-Med: a pilot investigation.

The purpose of this pilot investigation was to determine whether the incidence of bacteremia following subgingival ultrasonic scaling and root planing could be reduced by the use, pre- and intraoperatively, of an irrigant containing 0.12 per cent chlorhexidine (CHX); Prosol. Individuals having evidence of significant periodontal disease (minimum of seven sites per quadrant 4.0 mm and bleeding on probing) were entered into this study. By use of a random number table, patients were assigned to either the experimental or control groups. The procedures, as described below, were carried out in a double blind fashion so that neither the investigator nor the patient was aware of whether Prosol or placebo was being used. The placebo solution was flavored to make it indistinguishable from Prosol. Patients were first anesthetized. Their gingival crevices were then irrigated using the Cavi-Med ultrasonic scaler. At this point, the ultrasonic action was not activated. Ten minutes later, ultrasonic scaling and root planing with the Cavi-Med unit were begun with a continuous flow of either the placebo or control solutions. Blood samples were taken preoperatively, while postoperative samples were taken one minute after completing the scaling of each quadrant and then 10 minutes after scaling the second quadrant. Routine aerobic and anaerobic bacterial culture methods were used to identify viable blood-borne bacteria. The results show that there was no difference in the distribution or presentation of periodontal disease between the experimental and control quadrants.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed1999

An uncommon mechanism of brachial plexus injury. A case report.

PURPOSE: To report a case of brachial plexus injury occurring on the contralateral side in a patient undergoing surgery for acoustic neuroma through translabrynthine approach. CLINICAL FEATURES: A 51-yr-old woman underwent surgery for acoustic neuroma through translabrynthine approach in the left retroauricular area. She had a short neck with a BMI of 32. Under anesthesia, she was placed in supine position with Sugita pins for head fixation. The head was turned 45 degrees to the right side and the neck was slightly flexed for access to the left retroauricular area, with both arms tucked by the side of the body. Postoperatively, she developed weakness in the right upper extremity comparable with palsy of the upper trunk of the brachial plexus. Hematoma at the right internal jugular vein cannulation site was ruled out by CAT scan and MRI. The only remarkable finding was considerable swelling of the right sternocleidomastoid and scalene muscle group, with some retropharyngeal edema. An EMG confirmed neuropraxia of the upper trunk of brachial plexus. She made a complete recovery of sensory and motor power in the affected limb over the next three months with conservative treatment and physiotherapy. CONCLUSIONS: Brachial plexus injury is still seen during anesthesia despite the awareness about its etiology. Malpositioning of the neck during prolonged surgery could lead to compression of scalene muscles and venous drainage impedance. The resultant swelling in the structures surrounding the brachial plexus may result in a severe compression.

Brachial Plexus↗

PubMedDate not supplied

Postoperative astigmatism.

With the numerous significant advances in surgical methodology--e.g., microinstrumentation, the operating microscope, the surgical keratometer, and intraocular lenses--that have been developed over the past two decades, both surgeons and patients have become increasingly aware of the final optic result of any surgical intervention. This is especially so since the development of refractive surgery, where good uncorrected vision is frequently the final arbiter of success. We have progressed to the stage where the optic manipulation of the cornea, whether intentional or otherwise, can be understood in terms of a number of variables. These include the preparation and closure of the surgical wound, the choice of suture material, and both intraoperative and postoperative manipulations. Where these have failed and postoperative astigmatism still occurs, a number of surgical procedures are available to reduce the astigmatic error to an acceptable level.

Astigmatism↗

PubMed2001

The impact of herbal medicines on dermatologic surgery.

BACKGROUND: In recent years herbal medicines and supplements have become increasingly popular. With their increased popularity, more publications are warning about the potential harmful effects of some of these products. OBJECTIVE: To present scientific evidence of the benefits and surgical risks of herbal products. METHODS: A Medline search and review of the literature was performed. RESULTS: Many herbal medicines are relevant in dermatologic surgery since Ginkgo biloba, garlic, ginger, ginseng, feverfew, and vitamin E may increase the risk of bleeding, and ephedra may potentiate the side effects of epinephrine. CONCLUSION: Dermatologists should be aware of these herbal products and their uses. Many of these products prescribed by alternative medicine physicians or purchased over the counter should be discontinued prior to dermatologic surgery to minimize the risk of surgical complications.

Blood Loss, Surgical↗

PubMed2004

[Transient increase of bispectral index in a patient with bronchoconstriction after endotracheal intubation].

A 62-year-old woman (148 cm, 48.5 kg) with a history of bronchial asthma underwent an emergency appendectomy. Ten days before the operation she developed symptoms of wheezing while under asthma medication. An endotracheal tube (7 mm) was inserted after the induction of general anesthesia with intravenous injection of fentanyl 100 micrograms, propofol 100 mg and vecuronium 10 mg under Sellick's maneuver. Anesthesia was maintained with 1% sevoflurane with oxygen 6l-min-1 just after intubation, but bilateral lung sound soon became weaker and ventilation difficult. Based on a diagnosis of bronchoconstriction, we started hyperventilation with 3% sevoflurane. Ventilation returned to normal after about 5 minutes. Percutaneous O2 saturation was maintained at 100% during this episode, but the BIS transiently rose to 82. Anesthesia was maintained with 2% sevoflurane and 50% nitrous oxide balanced with oxygen, and 250 mg aminophylline was administered. Upon completion of the operation, the endotracheal tube was removed without any events. The patient gave no sign of awareness during the operation. When severe bronchoconstriction prevents the absorption of anesthetics from the lung alveoli, additional intravenous anesthetics should be administered to maintain stable amnesia.

Anesthesia, General↗

PubMed1987

Complicated implantations of inflatable penile prostheses.

In conclusion, implantation of an inflatable penile prosthesis into a normal penis is usually a relatively uncomplicated procedure, but the urologist should be aware of the possibility of complications described in this article. He must be familiar with the advantages and disadvantages of the various prostheses and the surgical techniques required to deal with the problems encountered in complicated as well as in routine prosthetic penile implants.

Erectile Dysfunction↗

PubMed1995

Clinical significance of leg-length inequality after total hip arthroplasty.

Sixty-eight patients were interviewed and examined after total hip arthroplasty (THA) to determine the clinical consequences (patient satisfaction, shoe lift use, gait abnormalities, etc) of leg-length inequality. No patient met clinical or radiographic criteria for revision THA. Minimum follow-up was 2 years, and average follow-up was 6.6 years (range, 2 to 20.5 years). A questionnaire, with specific questions about leg-length inequality, was completed by each patient. Leg-length inequality was determined by orthoroentgenography and compared with clinical measurements of leg length. The average inequality in this series of patients was 9.7 mm. A significant number (32%) of patients were aware of this inequality; the average leg-length inequality in this group was 14.9 mm. More than half of these patients were disturbed by the inequality. The magnitude of leg-length inequality closely correlated with awareness of the inequality, abnormal gait, use of ambulatory assistive devices, the need for a shoe lift, prior leg-length inequality, and revision THA. Clinical measures of leg-length inequality correlated poorly with values determined orthoroentgenographically. The high rate of dissatisfaction among patients with a leg-length inequality and the untoward results associated with this inequality indicate that surgeons performing THA should familiarize themselves with a reliable method for equalizing leg lengths intraoperatively.

Adult↗

PubMed1997

Mesenteric venous thrombosis.

MVT is an uncommon form of visceral ischemia. Symptoms and signs of MVT are usually nonspecific and should not be relied on for accurate diagnosis. A simple, logical diagnostic algorithm can be used to manage most of these patients (Fig. 6). CT or MRI appears to be the most sensitive diagnostic test and should be obtained early for any patient suspected of harboring MVT. Patients with peritonitis require prompt abdominal exploratory laparotomy to rule out ischemic bowel. Once the diagnosis of acute MVT is confirmed, the patient should be anticoagulated with heparin. During operation, all nonviable bowel should be resected with intent for a second-look laparotomy after 24 hours if there is any question of ongoing ischemia. We recommend using fluorescein-assisted evaluation of marginally viable bowel intraoperatively. After the operation, anticoagulation is continued with heparin and then oral warfarin sodium when the patient's bowel function returns. For those patients without peritonitis, we recommend prompt anticoagulation followed by at least a 48- to 72-hour period of close observation. All patients who have had an episode of acute MVT and do not have a contraindication to anticoagulation should be anticoagulated on a life-long basis with warfarin sodium. Despite our increased awareness of acute MVT, the 30-day mortality rate remains high. Acute MVT typically has a more insidious and unpredictable course than do other forms of visceral ischemic syndromes, with a mortality rate as high as that of its arterial counterpart. Although there has been a slight improvement in survival during the last 20 years, the recurrence rate remains high and the long-term prognosis is poor in this group of patients. Survival of patients with chronic MVT is better than that of those with acute MVT and appears to be determined by the underlying disease.

Acute Disease↗