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PubMed1999

Ascending aortic atherosclerosis--a complex and challenging problem for the cardiac surgeon.

Ascending aortic atherosclerosis is an increasingly recognized problem in cardiac surgery. It is the most important risk factor for perioperative stroke and seems to be in part responsible for postoperative neurobehavioral changes. Patients exhibiting ascending aortic atherosclerosis have a significantly reduced survival rate and are at considerable risk for spontaneous embolic stroke during the long-term postoperative course. Preoperative noninvasive diagnosis and intraoperative assessment by inspection or palpation of the aorta are insensitive. Intraoperative epiaortic ultrasound scanning has emerged as a most helpful tool for the diagnosis of ascending aortic atherosclerosis and has revealed major insights into the nature and distribution of this disease. Management strategies range from minimally invasive aortic "no touch" techniques to maximally invasive procedures, including application of deep hypothermic circulatory arrest. Operative modifications in coronary artery bypass grafting include avoidance of aortic crossclamping, alternative methods of aortic crossclamping and placement of all arterial in situ bypass conduits, Y-grafts or extra-anatomical bypass grafts. Other operative strategies include modifications of the arterial cannulation site, replacement of the ascending aorta or ascending aortic endarterectomy. One of the most recently developed methods is embolic capture by intraaortic filters. Increased awareness of ascending aortic atherosclerosis is critical in order to prevent the devastating complications it can cause during cardiac surgery.

Aortic Diseases↗

PubMed2001

EEG-bispectral index changes with ketamine versus thiamylal induction of anesthesia.

BACKGROUND: The EEG-Bispectral Index (BIS) is a processed EEG information that has been validated as a means to measure the hypnotic effect of anesthetic drugs. In this study we evaluated the BIS changes in induction of anesthesia with ketamine in comparison with that of thiamylal. METHODS: Forty ASA class I and II adult female patients undergoing elective gynecologic surgeries were enrolled into this randomized, prospective study. No premedication was given to the patient. In each patient EEG was recorded continuously from the frontal electrodes using Aspect A-1050 monitor after his arrival at the operating room. Blood pressure and heart rate were also recorded throughout the surgery. After steady baseline recordings of all necessary parameters having been accomplished Group K patients (n = 20) were given an induction dose of ketamine 1.5 mg/kg i.v., whereas Group T patients (n = 20) received thiamylal 5 mg/kg i.v. When loss of consciousness was ascertained, intubation was performed after administration of succinylcholine 1 mg/kg i.v. and anesthesia was maintained with isoflurane-nitrous oxide-oxygen. Demographics, BIS values, HR, BP were analyzed and compared. RESULTS: The demographics were comparable between the two groups. Both groups showed a mean value of BIS of 96 with comparable BP and HR before induction. After study drug the post-induction BIS for ketamine was 94 as against 51 for thiamylal (P < 0.05), 91 against 43 post-succinylcholine (P < 0.05), 92 against 53 post-intubation (P < 0.05) and 45 against 37 five min after isoflurane. BIS remained below 60 throughout the entire course of anesthesia and returned to above 95 on emergence in both groups. None of the patients reported awareness, recall, delirium or hallucination during anesthesia. CONCLUSIONS: Ketamine-induced dissociative anesthesia produces persistently elevated BIS index which is different from thiamylal and those reported with other conventional anesthetic agents. The established range of BIS index appears not to be applicable in patients under ketamine anesthesia. Monitoring the depth of ketamine anesthesia remains to be a challenging problem.

Adult↗

PubMed1985

Genitourinary trauma in children.

More children die from trauma than from any single disease. In children who sustain multiple injuries, urinary tract trauma is second only to trauma to the central nervous system. Most pediatric trauma is associated with vehicular and pedestrian accidents. However, the increased participation in contact sports and awareness of sports medicine injuries have increased the relative frequency and detection of sports-related injuries as well. Also, the urologist is frequently involved with, and may be legally responsible for, evaluation of children in possible abusive situations. The authors emphasize genitourinary injuries unique to the pediatric age group and update controversies in the management of more complex urologic injuries.

Adolescent↗

PubMed1994

Modes of presentation and management of inflammatory aneurysms of the abdominal aorta.

The preoperative diagnosis of inflammatory aneurysms of the abdominal aorta (IAAA) is seldom made, yet knowledge of its presence would be an aid to the surgeon. A heightened awareness of the variety of clinical presentations of IAAA should prompt the clinician to consider this entity in the differential diagnosis of back pain, weight loss and obstructive uropathy. Hypovolemic shock, gastrointestinal bleeding and asymptomatic IAAA have also occurred, albeit much less frequently. Patients who are hemodynamically stable might benefit from a short period of diagnostic and therapeutic measures before operation. Patients undergoing aneurysm repair on an "urgent" rather than "emergent" basis have been shown to have lower mortality and morbidity rates with enhancement of their cardiopulmonary and renal status. Computed tomographic scanning preoperatively in stable patients using careful supervision can confirm the diagnosis and allow more time for patient and surgical team preparation. Knowledge and avoidance of technical pitfalls intraoperatively further lessens mortality and complications.

Aged↗

PubMed2004

Sonification supports eyes-free respiratory monitoring and task time-sharing.

Three experiments explored the effectiveness of continuous auditory displays, or sonifications, for conveying information about a simulated anesthetized patient's respiration. Experiment 1 established an effective respiratory sonification. Experiment 2 showed an effect of expertise in the use of respiratory sonification and revealed that some apparent differences in sonification effectiveness could be accounted for by response bias. Experiment 3 showed that sonification helps anesthesiologists to maintain high levels of awareness of the simulated patient's state while performing other tasks more effectively than when relying upon visual monitoring of the simulated patient state. Overall, sonification of patient physiology beyond traditional pulse oximetry appears to be a viable and useful adjunct to visual monitors. Actual and potential applications of this research include monitoring in a wide variety of busy critical care contexts.

Adult↗

PubMed2001

Angiomyofibroblastoma of the vulva: report of a case.

A 45-year-old woman was first seen by us 2 years after becoming aware of a slightly painful subcutaneous mass in her left vulva. The mass was 7.5 x 3.0 cm in size, well circumscribed, mobile, and rubbery. It was at first clinically considered to be a benign tumor. Microscopically, the resected mass was composed of spindle or polygonal tumor cells which were cellularly or hypocellularly arranged with perivascular accentuation in a mucoid or fibrocollagenous background. Immunohistochemically, myxoid tumor cells were positive for vimentin but not for alpha-smooth muscle actin, CD34, CD31, desmin, or S-100 protein. The tumor was diagnosed as an angiomyofibroblastoma (AMBF), based on the typical findings of histology and immunohistochemistry. There are many histological types of vulvar tumors, and establishing a preoperative diagnosis is difficult in many patients. Rapid intraoperative pathological diagnosis should be performed if possible, considering the possibility of diseases such as AMFB and aggressive angiomyxoma (AAM). When AAM is suspected, the peripheral tissues should also be resected to prevent recurrence.

Angiofibroma↗

PubMed2003

Bispectral index changes following etomidate induction of general anaesthesia and orotracheal intubation.

BACKGROUND: Etomidate-associated hypnosis has only been studied using standard clinical criteria and raw EEG variables. We conducted a BIS-based investigation of etomidate induction of general anaesthesia. METHODS: Thirty hydroxyzine-premedicated ASA I patients were randomly allocated to receive etomidate 0.2, 0.3, or 0.4 mg kg(-1) intravenously over 30 s. The BIS was continuously recorded. A tourniquet was placed on a lower limb to record purposeful movements and myoclonia. Tracheal intubation was facilitated using rocuronium 0.6 mg kg(-1) when the BIS value was 50. The times to disappearance of the eyelash reflex, to a decrease in the BIS to 50, and to tracheal intubation were compared. The BIS values 30 s following tracheal intubation, and mean arterial pressure (MAP) and heart rate (HR) at all time points were also recorded. RESULTS: The BIS value decreased to 50 for tracheal intubation with no purposeful movement in all but one patient in the 0.2 mg kg(-1) group. There was no difference between the etomidate groups (0.2, 0.3, and 0.4 mg kg(-1)) in regards to time to loss of the eyelash reflex (103 (67), 65 (34), 116 (86) s, P=0.2), or to a decrease in BIS to 50 (135 (81), 82 (36), 150 (84) s, P=0.1). Also, the BIS value 30 s after intubation (41 (10), 37 (4), 37 (4), P=0.4), and plasma etomidate concentrations (161 [29-998], 308 [111-730], 310 [90-869] ng ml(-1), P=0.2) did not differ between groups. The time to loss of the eyelash reflex was 12-140 s shorter than the time to a decrease in BIS to 50 in three patients in each group who received etomidate 0.2 and 0.4 mg kg(-1), and in four patients who received 0.3 mg kg(-1). No awareness was recorded. MAP and HR increases following tracheal intubation were comparable between groups. CONCLUSIONS: Etomidate induction doses do not predict the time for BIS to decrease to 50 as this variable varies markedly following three etomidate dose regimen.

Adult↗

PubMed2004

Lower limb (well leg) compartment syndrome after urological pelvic surgery.

PURPOSE: Well leg compartment syndrome (WLCS) is being seen more frequently as the complexity and duration of pelvic urological surgery increases, ie reconstruction/radical cancer surgery. The etiology of WLCS is multifactorial and prevention should form the mainstay of treatment. With significant morbidity and mortality, in particular lower limb morbidity secondary to fasciotomy wounds and long-term neurological sequelae, all urologists should be aware of this iatrogenic complication and how to prevent or treat it when it occurs. MATERIALS AND METHODS: A retrospective review of the world literature using MEDLINE was performed from 1966 to 2002, searching for lower limb compartment syndrome (well leg compartment syndrome), and its association with the lithotomy position and pelvic surgery. RESULTS: Although WLCS is not commonly reported in the urological literature, it has significant morbidity and mortality. The incidence of WLCS is probably under reported due to failed diagnosis or misdiagnosis. With increased awareness the incidence of this iatrogenic complication may be minimized or avoided altogether. CONCLUSIONS: Because the lithotomy position is one of the most common positions used in urology, it is mandatory for urologists to be familiar with the complications associated with it. If this complication is recognized early, prompt treatment decreases morbidity and mortality. Minimizing the risk of WLCS will leave urologists less open to litigation, which may follow this significant iatrogenic complication.

Compartment Syndromes↗

PubMed2004

Perioperative detection of brain oxygenation and clinical outcomes in cardiac surgery.

Awareness of the high incidence of subtle central nervous system dysfunction after cardiopulmonary bypass, when it leads to increased vigilance in monitoring and diagnosis, remains the most important factor in the detection of postoperative injury. Preliminary data from an ongoing prospective study indicates that the use of noninvasive cerebral oximetry may be associated with a decreased length of stay in patients who have had coronary artery bypass grafting.

Brain↗

PubMed2004

ECG signs mimicking acute inferior wall myocardial infarction are associated with elevated myocardial enzymes during isolation of pulmonary vein for focal atrial fibrillation.

In this study, we report an intraprocedural incident in patients undergoing ablation for atrial fibrillation. During left atrial manipulation our patients suffered from acute chest pain, showed ECG signs of an acute inferior wall myocardial infarction, and increased levels of cardiac Troponin I (cTnI). We strongly recommend being aware of unexpected reactions during isolating pulmonary veins for focal atrial fibrillation, especially when passing the dorsal part of the left atrium. If pericardial effusion is ruled out and ECG signs as well as symptoms disappear, the ablation procedure should proceed. We think patients undergoing pulmonary vein ablation for atrial fibrillation should be informed of this threatening complication.

Adult↗

PubMedDate not supplied

Reliability of preoperative ultrasonography evaluation for vitreoretinal surgery.

To evaluate the present level of reliability of common ultrasonography prior to vitreoretinal surgery, we carried out a prospective study to compare preoperative ultrasonography data with direct intraoperative findings. A total of 228 eyes with different vitreoretinal disorders and opaque or clear media were studied. In the group of 187 eyes with tractional retinal detachment (group I), the percentage of agreement between the ultrasonography data and the surgical findings ranged from 77.1% to 92.2%, depending on the pathology. In the group of 41 eyes without retinal detachment (group II), agreement ranged from 90.4% to 100%. The most frequent causes of failure of preoperative ultrasonography were incorrect prediction of macular detachment, partial posterior vitreous detachment, posterior vitreoschisis and vitreoretinal adhesions. The main cause of failure was the presence of multiple complicated echoes in group I, particularly in tractional diabetic retinal detachment. To achieve maximum benefits from ordinary preoperative ultrasonography, the vitreoretinal surgeon must be fully aware of its present level of reliability and general limitations.

Adolescent↗

PubMed2002

Frameless stereotaxy without rigid pin fixation during awake craniotomies.

OBJECTIVE: The accuracy and precision of resection with awake brain mapping is augmented when combined with frameless stereotaxy. Frameless stereotactic assisted surgery, however, typically involves immobilization in Mayfield pins. Rigid fixation, however, may be problematic for individuals undergoing awake craniotomy. We describe an alternate method of frameless stereotaxy without the use of pin fixation. METHODS: The MRI fiducials are placed in proximity to the proposed incision and prepared and draped in the operative field. After craniotomy, the epidural skull clamp (standardly used to support the electrode holder during corticography) is attached. Using the Stealth Navigational System, a spinal reference arc is then clamped onto the skull clamp base. After the fiducials and arc are registered, the probe is used for frameless guidance. RESULTS: In 14 of 15 cases (93%), this technique was successful. One case failed because of close proximity of the fiducials to the incision. The accuracy of the 14 successful cases was less than 4 mm. The error within the lesion itself was always less than 2 mm. Overall, these results are comparable to those achieved using a Mayfield head holder. In all tumor cases, postoperative imaging concurred with intraoperative assessment of a total versus subtotal resection. CONCLUSIONS: By affixing the spinal arc to the skull, the complications and discomfort associated with pin fixation are avoided completely. The patient is free to move without affecting the accuracy. The spine arc, in combination with the skull clamp, provides an efficient, well-tolerated, and accurate method of frameless navigation for the awake patient undergoing craniotomy.

Awareness↗

PubMed2006

Unrecognized sleep apnea in the surgical patient: implications for the perioperative setting.

UNLABELLED: Anesthesia and surgery both affect the architecture of sleep. Aside from the postoperative effects of anesthesia and surgery, sleep deprivation and fragmentation have been shown to produce apneas or desaturations even in patients without presumed sleep apnea. Recent epidemiologic data have placed the prevalence of obstructive sleep apnea syndrome (OSAS) at about 5% among Western countries. The problem is further hindered by the difficulty in diagnosing OSAS, as patients with OSAS may present for surgery without a prior diagnosis. Clinical suspicion for OSAS may first be recognized intraoperatively. Adverse surgical outcomes appear to be more frequent in OSAS patients. Immediate postoperative complications may intuitively be attributed to the negative effects of sedative, analgesic, and anesthetic agents, which can worsen OSAS by decreasing pharyngeal tone, and the arousal responses to hypoxia, hypercarbia, and obstruction. Later events are, however, more likely to be related to postoperative rapid eye movement (REM) sleep rebound. In the severe OSAS patient, REM sleep rebound could conceivably act in conjunction with opioid administration and supine posture to aggravate sleep-disordered breathing. REM sleep rebound has also been suggested to contribute to mental confusion and postoperative delirium, myocardial ischemia/infarction, stroke, and wound breakdown. Although the data to guide the perioperative management of patients with moderate-to-severe OSAS is scarce, heightened awareness is recommended. The selected use of therapy with nasal continuous positive airway pressure before surgery and after extubation may be beneficial. LEARNING OBJECTIVES: 1. Identify common sleep architectures affected by anesthesia and surgery in the perioperative period. 2. State a perioperative complication in Obstructive Sleep Apnea Syndrome patients. 3. Identify perioperative interventions and management techniques that best facilitate improved obstructive sleep apnea syndrome patient care.

Humans↗

PubMed2000

Cardiac surgery and neurological injury in children.

The freedom of children from vascular disease makes them an ideal population in which to study the deleterious effects of cardiopulmonary bypass. Cerebral embolic injury arises intraoperatively from air in the cardiac chambers and monitoring lines, particularly those in the left atrium. Postoperative emboli are more common in patients with single ventricle physiology, especially following a bidirectional Glenn shunt or Fontan procedure. Poor cannula selection or placement during bypass can cause maldistribution of the perfusate and cerebral injury. Postoperative hyperthermia can cause brain damage. Results of prospective and retrospective studies of neurological and developmental outcome after paediatric cardiac surgery at the Children's Hospital, Boston, have led to the following inferences: the use of circulatory arrest should be minimised; the pH stat strategy is preferred for cardiopulmonary bypass over the alpha stat strategy. A higher haematocrit on bypass, for example 30%, may be preferable to 20%; postoperative fever should be strenuously avoided. Surgeons should be aware that cardiopulmonary bypass parameters can have subtle but important effects on late developmental outcome.

Journal Article↗

PubMed1996

Intra-operative pneumatic tourniquet--perceptions of use and complications in the orthopaedic community of South Africa.

OBJECTIVES: To assess views on use, maintenance and side-effects of the pneumatic tourniquet in the South African orthopaedic community. METHODS: A census-type questionnaire study was conducted of all 475 orthopaedic surgeons registered with the Orthopaedic Association of South Africa during 1993/94. The chi-square test was used to determine statistical significance between different groups of respondents. RESULTS: Seventy-seven per cent of the questionnaires were returned. Ninety-nine per cent of respondents used a pneumatic tourniquet. Eighty-four per cent believed that the tourniquet may damage underlying tissue both as a result of applied pressure effects and ischaemic consequences. Fifty-four per cent of respondents personally checked the calibration of the pneumatic tourniquet, although 76% of respondents believe that the apparatus needs to be checked at least once per month. More respondents who did not check the tourniquet apparatus than respondents who did check it believe that applied pressure does not cause tissue damage (P < 0.001), that the operating room technician or hospital engineer should be responsible for checking equipment (P < 0.001), and that equipment did not need to be checked more than once every 6 months (P < 0.001). CONCLUSIONS: Although most orthopaedic surgeons are aware of the pneumatic tourniquet's side-effects, a minority appear to be unaware of the hazards of excessive applied pressure alone or excessive applied pressure caused by use of faulty equipment. It needs to be emphasised to these surgeons that regular checking of the pneumatic tourniquet apparatus is necessary in order to prevent postoperative complications ascribed to use of the tourniquet.

Bandages↗

PubMed1995

Risk factors for cerebral injury and cardiac surgery.

Cerebral complications represent the leading cause of morbidity after cardiac operations. With the growing awareness of their social and economic importance, increasing attention is being given to their prevention. In the coronary artery bypass population, advanced age (> or = 75 years) is associated with an 8.9% neurologic deficit rate. Mortality is increased ninefold in the elderly patient with a neurologic deficit. Cardiopulmonary bypass has long been recognized as a cause of neuropsychologic deficits. Emboli are thought to be the causal agent. Retinal microvascular lesions during cardiopulmonary bypass as well as recent demonstration of widespread pathologic subcapillary arteriolar dilatations in the brain after cardiopulmonary bypass have been documented. Despite widespread interest in cerebral blood flow and neurologic deficits, there is no convincing evidence that defines a critically low or dangerously high level of flow. The ascending aorta represents a leading source of embolic neurologic injury. The use of intraoperative ultrasound to identify the diseased aorta may result in alternative operative strategies in an effort to minimize emboli and improve neurologic outcome. Existing literature offers conflicting views on optimal management of carotid artery stenosis in the coronary artery surgical patient. A trend that combined carotid endarterectomy and coronary artery bypass may often be appropriate will need confirmation through a multicenter clinical trial. Open cardiac surgical procedures, particularly in the aged population, carry a significant increased risk of adverse neurologic outcome. Postoperative arrhythmias may result in embolic neurologic deficit. A further understanding of risk factors for cerebral injury will be of value in developing therapeutic approaches to this major clinical problem.

Brain Diseases↗

PubMed2002

Auditory evoked potential monitoring with the AAITM-index during spinal surgery: decreased desflurane consumption.

BACKGROUND: The auditory evoked potential (AEP) is sensitive to the depth of anesthesia. The A-line monitor is a novel device that processes the amplitude and latency of the AEP during the mid-latency time window to provide a simple numerical index, the AAItrade mark-index. The hypothesis of the present study was that titration of anesthetic depth (desflurane) by means of the AAItrade mark-index could decrease the consumption of the main anesthetic and shorten emergence times. METHODS: Thirty ASA I-II patients scheduled for elective open spine surgery under general anesthesia were randomly allocated to two groups. Group I (n=15), the main anesthetic, desflurane, was titrated with a target AAItrade mark-index of 20+/-5. Group II (n=15), desflurane was titrated according to routine clinical signs, including heart rate, blood pressure, sweating and tears. No fixed MAC-multiple was sought. The primary study variable was desflurane consumption; and secondary study variables were time to extubation and orientation. RESULTS: All patients had an uncomplicated course and no patients showed signs of awareness or had any recall postoperatively. AAItrade mark-index guidance reduced desflurane consumption by 29% and improved emergence. Time until extubation and orientation and ability to state name and date of birth was significantly shortened among AAItrade mark-index titrated patients. CONCLUSION: Titrating depth of desflurane anesthesia using AAItrade mark-index guidance decreased main anesthetic consumption and improved emergence during spine surgery.

Aged↗

PubMed2004

Optimizing patellofemoral tracking during total knee arthroplasty.

Fifty-seven patients who underwent 65 primary TKAs between 1993-1994 were retrospectively studied to identify the technical challenges and pitfalls associated with patellar resurfacing and to improve patellar tracking during total knee arthroplasty (TKA). Average patient age was 69 years. All surgeries were performed by a single surgeon (J.N.I), and the same prosthesis was used in all patients. Intraoperatively, attention was paid to avoid femoral and tibial component malrotation and prevent overstuffing of the patellofemoral joint. Preoperative limb alignment was varus in 42 knees, neutral in 6 knees, and valgus in 17 knees. Average pre-resection patellar thickness measured 23.8 mm and post-resection thickness averaged 21.5 mm. No patella-prosthesis composite was thicker than the native patella. Two (3%) knees required a formal lateral release to improve patellar tracking at surgery. Average follow-up for 53 patients (61 knees) was 5 years. At latest follow-up, 4 (6%) patients reported mild anterior knee pain, 5 (7%) patients reported pain with stairs, and 2 (3%) patients had knee crepitus without pain. No dislocations or recurrent subluxations occurred. No patient required revision surgery for patellofemoral complication. Awareness of the anatomic variability, attention to component rotation, and restoration of the normal patellar height improves patellar tracking and minimizes patellofemoral instability following TKA.

Aged↗