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PubMed2003

Surgical resection of gliomas WHO grade II and III located in the opercular region.

BACKGROUND: Surgery in the opercular region especially in the dominant hemisphere impose a major challenge for the neurosurgeon due to the close vicinity to functional important motor and speech areas. The purpose of the present study is to analyse on a homogenous patient group pre- and postoperative functional deficits with regard to different speech qualities (e.g. aphasia, apraxia), and to correlate these data with MR and intraoperative monitoring results. METHOD: Fourteen patients with suspected low grade astrocytomas in the opercular region consecutively treated by surgery were eligible for this study (histology revealed 3 WHO grade III tumours). Degree and duration of postoperative deficits were retrospectively evaluated according to tumour location and boundaries on MR, intraoperative neuromonitoring results and extent of tumour resection. FINDINGS: Postoperatively, 8 patients showed speech or language disturbances, in 4 patients combined with motor deficits mainly of the contralateral upper extremity. Fifty percent of the neuropsychologically tested patients exhibited speech apraxia while the other 50% had a true aphasic syndrome. Recovery of the latter deficits was in general faster and more complete. The severity and duration of postoperative deficits was in good correlation with the distance of the resection margin to the next positive stimulation point(s), and a distance of more than 0.5 cm proved to avoid major impairments. The distribution of functional important stimulation points in relation to the tumour extension was not predictable, and -- unexpectedly -- up to 50% of these sites were found overlaying the tumour. INTERPRETATION: Surgery for WHO grade II and III gliomas in the opercular region can result in speech apraxia or an aphasic syndrome with or without concomitant motor deficits. Intraoperative cortical electrical stimulation is essential in resecting tumours in the opercular region to avoid permanent morbidity.

Adolescent↗
PubMed1980

Operation for chronic constrictive pericarditis: Do the surgical approach and degree of pericardial resection influence the outcome significantly?

Our experience with 27 patients undergoing pericardiectomy at New York University Medical Center over the past 13 years has evolved a radical pericardiectomy operation suggesting that two traditional concepts are erroneous: (1) pericardiectomy limited to the anterior and lateral surfaces of the ventricles is an adequate operation and (2) delayed recovery is due to myocardial "atrophy" and not to inadequate operation. Radical pericardiectomy entails removal of virtually the entire parietal pericardium from all cardiac surfaces including that of both ventricles, the right atrium, and the venae cavae. Performed in 22 patients by dissecting a cleavage plane between the thickened parietal pericardium and underlying epicardium, all procedures were done through a sternotomy. Intraoperative monitoring of arterial pressure, cardiac output, and wedge pressure is essential because of displacement of the left ventricle. The left ventricle can be completely mobilized so that at the end of the operation the entire heart can be lifted upward and the course of the coronary sinus fully visualized. Intraoperative pressure measurements demonstrate that this radical resection immediately corrects hemodynamic abnormalities (elevated right atrial and ventricular end-diastolic pressures), as demonstrated in 10 patients. Most patients undergo massive diuresis (7 to 16 kg) within two weeks, with an uneventful recovery. These findings contrast markedly with early experiences using a conventional limited pericardiectomy.

Adolescent↗
PubMed1986

Plasma ionized calcium monitoring during liver transplantation.

Plasma ionized calcium and citrate concentrations were measured in 11 patients undergoing liver transplantation. During the anhepatic phase of the procedure, ionized calcium concentrations fell to as low as 40% of normal, in spite of calcium supplementation. Simultaneously, citrate concentrations rose to between 20 and 100 times preoperative levels. In two patients low plasma ionized calcium concentrations were associated with hypotension that responded to calcium infusion. Intraoperative monitoring of plasma ionized calcium during liver transplantation is helpful in the rational control of the patient's calcium status.

Calcium↗
PubMed2002

Assessing sedation with regional anesthesia: inter-rater agreement on a modified Wilson sedation scale.

UNLABELLED: A valid and reliable means for measuring sedation during regional anesthesia would be valuable for both research and practice. Current methods of monitoring sedation include machine-, patient-, and observer-based assessment. The reliability of machine-based methods is limited at lower levels of sedation, whereas patient-based methods are impractical at higher levels. Observer-based methods offer the best alternative for assessing sedation during regional anesthesia; however, their reliability has not been adequately documented. We examined the interrater reliability of the Wilson sedation scale. Sedation was assessed by pairs of anesthesia care providers in 100 patients undergoing surgical procedures with regional anesthesia. On the basis of the findings, the scale was modified, and 50 additional patients were assessed. The study protocol called for a series of standardized stimuli administered by a research assistant. Raters were blinded to each other's ratings. Interrater reliability was assessed by using the kappa statistic, a measure of actual agreement beyond agreement by chance. When continuing checks on its operationalization and reliability are included, the modified Wilson scale provides a simple and reliable means by which to assess and monitor intraoperative sedation. IMPLICATIONS: We evaluated the interrater reliability of the Wilson scale for measuring sedation during regional anesthesia. Paired anesthesia care providers' ratings of patient sedation indicated very good interrater reliability in both the original scale and a modified version. The modified Wilson scale provides a quick noninvasive means of monitoring sedation during regional anesthesia.

Adolescent↗
PubMed2000

Intraoperative parathyroid hormone analysis: A study of 200 consecutive cases.

BACKGROUND: Immunoassays for parathyroid hormone (PTH), with short incubation times and results available in <15 min, have allowed intraoperative monitoring of the success of parathyroid surgery. The purpose of this study was to evaluate the analytical performance of a rapid PTH assay and its clinical performance in a series of 200 patients. METHODS: PTH was measured with a modified immunochemiluminometric assay with a 7-min incubation time (QuiCk-IntraOperative(TM) Intact PTH assay). The rapid assay was compared with results in a central laboratory (immunoradiometric assay) in 44 EDTA-plasma specimens. The rapid assay was used intraoperatively in 200 consecutive cases with specimens analyzed before and 5-10 min after resection of the hypersecreting parathyroid gland(s). RESULTS: Intraassay imprecision was 12% at 28 ng/L and 11% at 278 ng/L. Regression analysis of results of the rapid PTH assay and the IRMA PTH assay in 44 parathyroidectomy patients yielded y = 1.26x - 12 ng/L, S:(y|x) = 26.3 ng/L, r = 0.984, and in 40 of 44 patients with values <200 ng/L, y = 1.02x + 1.9, S:(y|x) = 13.9, r = 0.947. In the 195 cases using intraoperative PTH testing with complete results and defined clinical outcomes, the overall accuracy of the assay in predicting surgical success was 88% using the criterion of a 50% decrease at 5-10 min and 97% including the subset of patients with delayed decreases of PTH. CONCLUSIONS: The rapid PTH assay had excellent analytical performance and excellent agreement with the PTH immunoradiometric assay and predicted the success of parathyroid surgery in this large series of consecutive patients.

Adolescent↗
PubMed2003

Anesthesia related complications of laparoscopic cholecystectomy.

OBJECTIVE: To determine the incidence of intraoperative anesthesia-related complications of laparoscopic cholecystectomy. DESIGN: A descriptive study. PLACE AND DURATION OF STUDY: The study was conducted in Anesthesia Department of Hayat Shaheed Teaching Hospital, Peshawar from April 1995 to April 1996. SUBJECTS AND METHODS: One hundred consecutive patients (ASA I and ASA II) were anesthetized and monitored intraoperatively for detection of complications. The operative findings and data were recorded on a proforma and finally the results were analyzed. RESULTS: One hundred patients with male to female ratio of 1: 8.09 in the age range of 20-80 years (mean 39 years) underwent general anesthesia for laparoscopic cholecystectomy. The duration of operation in 94 laparoscopic cholecystectomy was from 20 to 80 minutes (mean 60.63 minutes ).The incidence of intraoperative hypotension was 9%. Four percent of the patients developed arrhythmias. Increase in end-tidal-carbon dioxide (ETCO2) was observed in 3% of cases. Conversion rate to open cholecystectomy was 6%. Damage to intraabdominal vessels with trocar insertion occurred in 1% of cases. CONCLUSION: Although laparoscopic cholecystectomy has major surgical and anesthetic advantages, there are anesthesia related complications requiring specific anesthetic interventions to improve patients outcome without compromising their safety.

Adult↗
PubMed1988

Laser Doppler flowmetry estimating myocardial perfusion after internal mammary artery grafting.

Myocardial perfusion in the anteroapical part of the left ventricle was monitored intraoperatively with laser Doppler flowmetry in ten patients after grafting of the internal mammary artery to the left anterior descending artery. The myocardial perfusion after declamping of only the mammary artery averaged 61% of the perfusion found after declamping also the aorta. Laser Doppler flowmetry is proposed to offer a means of monitoring regional myocardial perfusion in the phase immediately after internal mammary artery grafting.

Coronary Artery Disease↗
PubMed1994

Prediction of intracerebral haemorrhage after carotid endarterectomy by clinical criteria and intraoperative transcranial Doppler monitoring: results of 233 operations.

OBJECTIVE: Identification of predictors of intracerebral haemorrhage after carotid endarterectomy. DESIGN: Retrospective comparison of patients who developed intracerebral haemorrhage and patients who did not, with special attention to intraoperative transcranial Doppler monitoring of the ipsilateral middle cerebral artery and postoperative signs and symptoms of hypoperfusion. SUBJECTS AND MATERIALS: Two-hundred and thirty-three patients were studied with regard to the increase of peak blood flow velocities and pulsatility indices after endarterectomy and to the occurrence of unilateral throbbing headache or hypertension. RESULTS: Intracerebral haemorrhage occurred in five cases. Seventeen patients complained of headache or showed hypertension, four of whom developed an intracerebral haemorrhage (p < 0.001; Fisher's exact test). The positive predictive value of headache, hypertension, or both, was 24% (diagnostic gain 22%). The negative predictive value, sensitivity and specificity were 99, 80 and 94%, respectively. The increase of peak blood flow velocities and pulsatility indices in patients who developed intracerebral haemorrhage was significantly higher than in patients who did not (p < 10(-5); one-way ANOVA). When cut-off levels for the increase of peak blood flow velocities and pulsatility indices were set to 175 and 100%, respectively, the positive predictive value of intraoperative transcranial Doppler was 100% (diagnostic gain 98%). The negative predictive value, the sensitivity and specificity were 99, 80 and 100%, respectively. CONCLUSION: An increase of peak blood flow velocity > or = 100% or pulsatility index > or = 100% after declamping predicts intracerebral haemorrhage more accurately than the occurrence of headache or hypertension. Transcranial Doppler monitoring can be used to identify patients at risk for intracerebral haemorrhage, in whom control of blood pressure and modest degrees of anticoagulation may be appropriate.

Cerebral Hemorrhage↗
PubMed1994

A new approach to parathyroidectomy.

OBJECTIVE: To decrease the operative time for parathyroidectomy in patients with hypercalcemic (primary) hyperparathyroid disease, a combination of preoperative localization of a parathyroid tumor with an effective nuclear scan (scintigram) and intraoperative monitoring of parathyroid hormone (quick parathyroid hormone measurement) to ensure excision of all hyperfunctioning tissue was studied. SUMMARY BACKGROUND DATA: For many years, persistent hypercalcemia after parathyroidectomy (3% to 10%) has been constant and is usually due to the surgeon's failure to remove all hyperfunctioning glands. A marked decrease in parathormone level after excision of a single large gland predicts operative success and a return to normal calcium levels. Conversely, persistent high levels of parathyroid hormone indicate excess secretion by another gland(s) and the need for further exploration. Recently Tc-99m-sestamibi (MIBI) scintigraphy was shown to be more effective in localizing parathyroid tumors than previous methods. A combination of both techniques could be useful to the surgeon if they improve the operative success rate and are cost-effective. METHODS: Parathyroidectomy was performed on 18 patients with primary hyperparathyroid disease, with tumors localized by MIBI scintigrams. When excision of the identified parathyroid gland was accomplished, the operation was terminated and quick parathyroid hormone was measured to confirm that all hyperfunctioning tissue was removed. RESULTS: Sixteen patients with positive results of scintigram had successful parathyroidectomies confirmed by quick parathyroid hormone measurement with a cervical approach. Two patients with mediastinal tumors localized by MIBI scintigraphy could not be resected using this approach. One false-positive/false-negative scintigram was obtained. Compared with patients having parathyroidectomy without localization and hormone monitoring, the average operative time was shortened from 90 to 36 minutes. CONCLUSIONS: Localization and successful excision of parathyroid tumors with confirmation that no other hyperfunctioning glands were present by quick parathyroid hormone monitoring can predict a return to normal calcium levels and a decrease in operative time in parathyroidectomy.

Humans↗
PubMed1980

Hemodilution and induced hypotension for insertion of a Harrington rod in a Jehovah's Witness patient.

The case of a 28-year-old Jehovah's Witness illustrates the feasibility of using a combined technique of induced hypotension and hemodilution to minimize the surgical loss of red blood cells during the insertion of a Harrington rod. A Swan-Ganz catheter with thermister tip was inserted to measure pulmonary arterial pressure, pulmonary arterial wedge pressure and cardiac output. Other intraoperative monitoring included continuous arterial pressure, electrocardiography, oropharyngeal temperature, esophageal stethoscope, arm-cuff blood pressure and urinary output from an indwelling Foley catheter. A total of 10 L of crystalloid was infused over a 2 1/2-hour period while hypotension was induced by intravenous nitroprusside and enflurane anesthesia. Hematocrit was diluted from 46% to 26% intraoperatively with an estimated surgical blood loss of 2,740 ml. The 24-hour postoperative hematocrit was 30% and recovery was uneventful. This method may be useful in any orthopedic procedure in which heavy blood loss is anticipated and the patient refuses transfusion of blood or blood products. However, the patient must be in good health and have an uncompromised cardiopulmonary system.

Adult↗
PubMed1992

Monitoring and cerebral protection during carotid endarterectomy.

Two recently published multicentre trials have confirmed the overall benefit of carotid endarterectomy in symptomatic patients with severe carotid artery disease. The key to improving further the long-term advantages of carotid endarterectomy, however, remains the continued reduction of the initial operative risk. While the principal responsibility for this continues to be borne by the surgeon, specifically in reducing technical error, the time is perhaps approaching when he or she might also be able to apply some of the recent advances in cerebrovascular research to reduce operative morbidity still further in the future. This article summarizes the aetiology and pathophysiology of operation-related neurological deficits and reviews current approaches towards intraoperative monitoring, cerebral protection and assessment of quality control.

Brain Ischemia↗
PubMed1994

Preoperative autonomic function abnormalities in patients with diabetes mellitus and patients with hypertension.

BACKGROUND: This study was done to assess whether or not autonomic function abnormalities identified patients with diabetes mellitus as being at risk for postoperative cardiac arrest or death. STUDY DESIGN: We prospectively studied 74 patients with diabetes mellitus and 118 patients with hypertension without diabetes mellitus undergoing elective noncardiac operation. The study was done at an academic medical center between 1982 and 1985. Patients were evaluated preoperatively, monitored intraoperatively by an independent observer and had daily follow-up evaluation for seven days postoperatively, according to a standard surveillance protocol. Outcomes were judged by assessors unaware of the preoperative status and intraoperative course. Patients were interviewed at three and five years postoperatively. RESULTS: Patients with diabetes mellitus with two or more abnormal autonomic function test results did not experience more intraoperative hypotension, nor did they require more intraoperative pressor agents than patients with diabetes mellitus with one or no abnormalities. Seven percent of the patients with diabetes mellitus experienced postoperative cardiorespiratory arrest or death. All of these patients had more than two abnormal autonomic function test results as well as a previous history of either myocardial infarction or cardiomegaly. CONCLUSIONS: While this study obviously requires confirmation in a larger population, the data are sufficiently strong to warrant close postoperative monitoring of all patients with diabetes mellitus who have two or more autonomic abnormalities.

Autonomic Nervous System↗
PubMed1994

Clinical assessment of biplanar transesophageal echocardiography--a report of 125 cases.

One hundred and twenty-five patients with cardiovascular disease were examined by biplanar transesophageal echocardiography (BTEE), including 67 with rheumatic heart disease (7 monitored during operation), 22 with aortic diseases, 20 with congenital heart diseases, and 16 with other kinds of heart disease. The results showed that BTEE was not influenced by corpulent and pulmonary emphysema and was better than transthoracic echocardiography at imaging the interatrial septum, left atrium and left atrial appendage, thoracic aorta, and mitral artificial valve and at intraoperative monitoring. BTEE was also better than single-plane transesophageal echocardiography, because BTEE could be used to observe the heart and thoracic aorta in transverse and longitudinal planes, thus enlarging the transmission "window" as well as allowing the entire lesion to be imaged. This study suggests that BTEE will have good prospects in clinical application.

Adolescent↗
PubMed1991

Ammonia elimination as a rapid index of viability in liver grafts in dogs.

We examined intraoperative changes in blood ammonia levels and the correlation with graft viability in orthotopic liver transplantation (OLTx) in 29 dogs. Blood ammonia levels following total hepatectomy were examined using five dogs. These levels immediately following hepatectomy (15 min) were significantly higher (212 +/- 29 micrograms/dl) over values noted before hepatectomy (93 +/- 11 micrograms/dl, P less than 0.05). OLTx was performed using the cuff technique. The animals were divided into two groups: Group A (n = 6 pairs), OLTx with a nonpreserved fresh graft; Group B (n = 6 pairs), OLTx with an 8-hr preserved graft with lactated Ringer (4 degrees C). In both groups, the blood ammonia levels before the surgery and at the anhepatic phase data did not differ; however, following reperfusion, the levels in Group B were significantly higher (211 +/- 26 at 15 min, 200 +/- 50 micrograms/dl at 30 min) than those in Group A (121 +/- 10 at 15 min; P less than 0.01, 109 +/- 9 micrograms/dl at 30 min; P less than 0.05). The blood ammonia level highly correlated with adenosine triphosphate contents in the liver tissue, blood level of lactic acid, and amount of bile output, all pertinent indicators of the graft viability. Thus, the potential to eliminate ammonia immediately after reperfusion can serve as an indicator of graft viability. The intraoperative monitoring of blood ammonia levels can be included in management guidelines in cases of liver transplantation.

Adenosine Triphosphate↗
PubMed1995

Predicting perioperative stroke.

The purpose of this review is to examine the incidence and mechanisms of perioperative stroke and to identify possible associated risk factors. The perioperative period can be subdivided into preoperative, intraoperative, and postoperative periods; we focus here on assessment in the preoperative period, as this is the time when risk prediction usually occurs. Surgical technique itself will not be considered, nor will intraoperative monitoring to detect cerebral ischemia be considered. This review will examine perioperative stroke in relation to general surgical procedures, including peripheral vascular reconstruction, orthopedic, gynecologic, and head and neck surgery.

Anesthesia↗
PubMed1989

Anesthetic management of the newborn.

Advances in monitoring technology, the availability of special skill, and training has resulted in the improved perioperative care of the newborn. With the coordinated efforts of pediatric anesthesiologists, pediatric surgeons, and neonatologists, safe anesthesia and surgery have become a reality even in a sick 500-gm premature infant. Fortunately for these nonverbal neonates, the personnel involved in this perioperative care are now more sensitive to their analgesic and anesthetic needs. With adequate preoperative preparation and intraoperative monitoring, safe anesthesia at present can be provided to most critically ill neonates, using the guidelines outlined above. In addition, the postoperative period also can be made pain free for them by a judicious selection of analgesic and local anesthetic drugs.

Anesthesia↗
PubMed2000

Anesthesia for the emergency small animal patient.

Anesthesia for the debilitated or emergency patient requires a thorough knowledge of the pharmacologic and physiologic effects of the anesthetic agents available. Preoperative evaluation and preparation of the patient, intraoperative monitoring and prompt attention to potential crises, and postoperative monitoring and pain management are all critical to the success of dealing with these cases. Special attention is devoted to cases with cardiovascular, respiratory, or neurologic instability.

Anesthesia, General↗