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PubMedDate not supplied

Progressive tumor necrosis and lethal hyperkalemia in a neonate with sacrococcygeal teratoma (SCT).

Tumor lysis syndrome is known among patients undergoing induction therapy for lymphocytic malignancies. Spontaneous tumor lysis in patients with solid tumors is distinctly rare. To our knowledge, the phenomenon of spontaneous tumor lysis has been described only once in infancy, in association with the surgical manipulation of a hepatoblastoma. This is the first report of a newborn with sacrococcygeal teratoma who experienced spontaneous tumor lysis-induced hyperkalemia. Because cardiac arrest may be among the leading causes of operative mortality in babies with sacrococcygeal teratoma, intraoperative monitoring of serum K+ should be conducted frequently.

Fatal Outcome↗
PubMed2005

Functional outcome after surgical treatment of intramedullary spinal cord tumors: experience with 78 patients.

OBJECTIVE: To analyze factors with impact on the functional outcome for patients with surgically treated intramedullary spinal cord tumors (IMSCT) and to point out characteristics of the different histological entities. SETTING: Neurosurgical Department, University of Essen, Germany. METHODS: Between 1990 and 2000, a consecutive series of 78 patients were referred to our institution and underwent surgical treatment. There were 46 (59%) male and 32 (41%) female patients. Mean age was 43.3 years. Functional outcome was analyzed depending on histological features, age, tumor localization and the extension of involved spinal segments. The mean follow-up period was 34.4 months. Operative removal of the IMSCT was performed under standard microsurgical conditions with intraoperative monitoring of somatosensory-evoked potentials (SSEP). RESULTS: The most frequently involved localization was the cervical and cervicothoracic region (55%) followed by the thoracic region (32%) and the medullar conus (13%). The most frequent IMSCTs were neuroepithelial tumors in 44 patients (56.5%) including 32 patients with ependymomas, 15 astrocytomas, and two lesions without further histological classification. Non-neuroepithelial tumors included 10 metastases, nine cavernomas, eight hemangioblastomas, one dermoidal cyst and one enterogenetic cyst. Complete tumor removal was achieved in 65 cases (83.3%) and subtotal resection in nine cases. In four cases a biopsy was performed only. The overall postoperative neurological state was improved or unchanged in 51 patients (65.4%) and worsened in 27 patients (34.6%). A favorable functional outcome was observed in 94.1% of patients with vascular tumors, in 61.3% of patients with low-grade neuroepithelial tumors and in 53.3% of patients with malignant tumors. CONCLUSIONS: The strongest predicting factor of functional outcome was the preoperative neurological condition beyond the histological differentiation of the IMSCT. Although there was no outcome difference with respect to the age and tumor extension, thoracically located IMSCTs proved to harbor an increased risk of postoperative surgical morbidity.

Adolescent↗
PubMed2001

Mortality associated with anaesthesia: a qualitative analysis to identify risk factors.

From a prospectively defined cohort of patients who underwent either general, regional or combined anaesthesia from 1 January 1995 to 1 January 1997 (n = 869 483), all consecutive patients (n = 811) who died within 24 h or remained unintentionally comatose 24 h after anaesthesia were classified to determine a relationship with anaesthesia. These deaths (n = 119; 15%) were further analysed to identify contributing aspects of the anaesthetic management, other factors and the appropriateness of care. The incidence of 24-h peri-operative death per 10 000 anaesthetics was 8.8 (95% CI 8.2-9.5), of peri-operative coma was 0.5 (0.3-0.6) and of anaesthesia-related death 1.4 (1.1-1.6). Of the 119 anaesthesia-related deaths, 62 (52%) were associated with cardiovascular management, 57 (48%) with other anaesthetic management, 12 (10%) with ventilatory management and 12 (10%) with patient monitoring. Inadequate preparation of the patient contributed to 30 (25%) of the anaesthesia-related deaths. During induction of anaesthesia, choice of anaesthetic technique (n = 18 (15%)) and performance of the anaesthesiologist (n = 8 (7%)) were most commonly associated with death. During maintenance, the most common factors were cardiovascular management (n = 43 (36%)), ventilatory management (n = 12 (10%)) and patient monitoring (n = 12 (10%)). In both the recovery and the postoperative phases, patient monitoring was the most common factor (n = 12 (10%) for both). For cardiovascular, ventilatory and other anaesthetic management, human failure contributed to 89 (75%) deaths and organisational factors to 12 (10%). For inadequate patient monitoring, human factors contributed to 71 (60%) deaths and organisational factors to 48 (40%). Other contributing factors were inadequate communication (30 deaths (25%) for all four aspects of the anaesthetic management) and lack of supervision (particularly for ventilatory management). Inadequate care was delivered in 19 (16%) of the anaesthesia-related deaths with respect to cardiovascular management, in 20 (17%) with respect to ventilatory management, in 18 (15%) with respect to patient monitoring and in 23 (19%) with respect to other anaesthetic management.

Anesthesia↗
PubMed1997

Biochemical markers of cerebral damage.

Neuroprotective therapy is likely to be most effective in preventing or minimizing the effects of cerebral ischaemia when given as early as possible after the insult. Neuropsychological testing is the gold standard for assessing minor cerebral damage, but is carried out several days or weeks after surgery and is too late to be useful for instituting therapy. Current intraoperative cerebral monitors (EEG, CFAM, NIRS and TCD) can detect cerebral ischaemia with good sensitivity, and give immediate results, but their specificity for ischaemia is low. Biochemical markers offer the possibility of rapid and specific diagnosis of cerebral ischaemia which would allow the early institution of neuroprotective therapies.

Biomarkers↗
PubMed2001

Safety and efficacy of peribulbar block as adjunct to general anaesthesia for paediatric ophthalmic surgery.

METHODS: Fifty children (age 5-14 years, ASA I-II) undergoing elective ophthalmic surgery were chosen for the study. Of these, 25 received intravenous pethidine (control group) and 25 received a peribulbar block (block group) for perioperative analgesia, and were monitored intraoperatively and postoperatively by an investigator blinded to the analgesic technique. RESULTS: Intraoperative values of haemodynamic variables were significantly higher in the control group (P < 0.01). Requirement for intraoperative rescue analgesic and postoperative analgesia was higher in the control group (P < 0.05 and P < 0.001, respectively). Children in the block group had lower postoperative pain scores at all times. Incidence of oculocardiac reflex was significantly higher (P < 0.001) in the control group. Seventy-six percent of children in the control group had postoperative nausea and vomiting compared to 20% children in the block group (P < 0.001). CONCLUSION: There were no complications related to the block. Peribulbar block appears to be a safe and useful analgesic technique for paediatric ophthalmic surgery.

Adolescent↗
PubMed2005

Implications and outcome of permanent coronary sinus lead extraction and reimplantation.

OBJECTIVE: We examined the implications and outcome of coronary sinus (CS) lead removal including the feasibility of laser use within the CS. BACKGROUND: Cardiac anatomy and lead interactions are more complex with the advent of biventricular pacemakers and atrial cardioverters requiring permanent lead/shocking coil placement in the coronary sinus and its branches. METHODS: Fifty-five permanent cardiac leads were extracted during 2003 in 28 consecutive patients. Our study population included a 10/55 (18%) subset (all males; age 73 +/- 6 years; EF = 0.24 +/- 0.09) that underwent CS (1/10) or vein branch (9/10) lead extraction. Leads were extracted with an excimer laser sheath (n = 4) or by direct traction (n = 6). Median times between implantation and lead removal were 9.5 months (range 5-59) in the laser group and 3 months (range 3-4) in the direct traction group. Indication for extraction was infection (n = 4), dislodgement (n = 3), diaphragm stimulation (n = 2), and elevated threshold (n = 1). The CS was divided into distal, mid, and proximal segments by venogram. RESULTS: Entry of the laser sheath into the CS was necessary in three of four laser patients. The two distal CS laser cases (left lateral CS coil and anterior-lateral left ventricular (LV) lead) required both 14- and 12-Fr sheaths, separately. The proximal CS laser case (posterior-lateral LV lead) required a 12 Fr sheath. The remaining laser patient required a 12-Fr sheath to pass to the mid SVC. There were no procedural complications as a result of CS lead extraction. Reimplantation of a CS lead was attempted in 7/10 patients at a median of 4 days (range 1-300). CS venograms were available for review in patients before initial implantation (6/10) and after extraction (7/10). The postextraction venograms demonstrated complete occlusion of the vein from which the lead was extracted, and its distal branches, which were unusable in 5/10 (50%). The vein occlusions were present in patients with indwelling leads for greater than 3 months and were independent of extraction method. CONCLUSIONS: Laser lead extraction in the coronary sinus appears feasible in carefully selected cases with mandatory indications. However, special intraoperative monitoring and echocardiographic imaging with surgical backup ready is strongly recommended. Target vein selection may be limited for the purpose of reimplantation when leads are indwelling for greater than 3 months.

Aged↗
PubMedDate not supplied

Endonasal endoscopic treatment of medial orbital wall fracture via rotational repositioning.

Various surgical approaches have been employed to treat the medial orbital wall fracture. It has been necessary to use grafts or splints in these approaches. We introduced a new technique to treat our patient with diplopia resulting from medial orbital fracture. In this new method, rotational repositioning of the fractured segment eliminates the use of any graft or synthetic material in the nose, ethmoid sinuses, or the orbit. The procedure could be done under local anesthesia, which facilitates intraoperative monitoring of the ocular movements to evaluate improvement of diplopia. Rotational repositioning technique could be an effective alternative method to previous approaches in treatment of selected medial orbital wall fractures.

Adult↗
PubMed2000

Rapid diagnosis and management of thoracic aortic dissection and intramural haematoma: a prospective study of advantages of multiplane vs. biplane transoesophageal echocardiography.

AIMS: The purposes of this study were to compare the accuracy of multiplane vs. biplane transoesophageal echocardiography (TEE) in the diagnosis of aortic dissection and aortic intramural haematoma, and to test whether these techniques provide all the diagnostic information required to make management decisions. METHODS AND RESULTS: Fifty-eight consecutive patients with clinically suspected aortic dissection were studied with multiplane TEE; all cases who required surgery underwent intraoperative monitoring with multiplane TEE. The following multiplane TEE data were analysed: the angle between current and 0 degrees plane at which each view was obtained; the success rate in the evaluation of true and false lumen, entry tear, coronary artery involvement, aortic regurgitation, pericardial effusion. Advantages of multiplane over biplane TEE have been evaluated by the demonstration of usefulness of views obtained in planes other than 0 degrees-20 degrees or 70 degrees-110 degrees, assuming that with manipulation of a biplane probe a 20 degrees arc could be added to the conventional horizontal and vertical planes. On the basis of TEE findings, aortic dissection was confirmed in 36 cases (18 type A, 12 type B, six intramural haematoma). The specificity and sensitivity of TEE in terms of the presence or absence of aortic dissection or intramural haematoma were 100%. An additional clinical value of multiplane over biplane TEE in the evaluation of ascending aorta, aortic arch, entry tears and coronary artery involvement was demonstrated. All cases with type A aortic dissection or intramural haematoma involving the ascending aorta had an operation that was performed immediately after the diagnosis (hospital mortality, 13%). Patients with type B aortic dissection were treated medically; 25% of these cases were operated later (hospital mortality, 0%). CONCLUSIONS: Multiplane and biplane TEE have excellent and similar accuracies in the evaluation of aortic dissection and intramural haematoma. Multiplane TEE improves the visualization of coronary arteries, aortic arch and entry tears; it appears to be an ideal method as the sole diagnostic approach before surgery in type A aortic dissection.

Adult↗
PubMed2004

Comparison of esophageal Doppler, pulse contour analysis, and real-time pulmonary artery thermodilution for the continuous measurement of cardiac output.

OBJECTIVE: Continuous measurement of cardiac output (CCO) is of great importance in the critically ill. However, pulmonary artery thermodilution has been questioned for possible complications associated with right heart catheterization. Furthermore, measurements are delayed in the continuous mode during rapid hemodynamic changes. A new pulmonary artery catheter CCO device (Aortech, Bellshill, Scotland) enabling real-time update of cardiac output was compared with 2 different, less-invasive methods of CCO determination, esophageal Doppler and pulse contour analysis. DESIGN: Prospective, observational study. SETTING: University hospital, single institution. PARTICIPANTS: Patients scheduled for elective coronary artery bypass grafting (CABG). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: CCO measurements were analyzed using a Bland-Altman plot. Bias between CCO and pulse contour cardiac output (PCCO), and Doppler-derived cardiac output (UCCO) was (mean +/- 1 SD) -0.71 +/- 1 L/min versus -0.15 +/- 1.09 L/min, and between UCCO and PCCO -0.58 +/- 1.06 L/min. Bias was not significantly different among methods, nor were comparative values before and after cardiopulmonary bypass (p > 0.05). CONCLUSIONS: Agreement between the CCO method and both less-invasive measurements was clinically acceptable. There were no adverse events associated with the use of either device.

Aged↗
PubMed2001

[Severe multiorgan failure caused by aspiration with laryngeal mask airway].

We report a case of a 77-year-old woman who developed severe multiple organ failure after aspiration with the LMA during ureteral splinting. Two hours after induction of anaesthesia the urologists decided for nephrostomy in prone position. Therefore the patient was intubated. During removal of the LMA bilious secretion was recognized inside the LMA and in the pharynx. Endotracheal suction and immediate bronchoscopy showed severe aspiration. After the operation the patient was submitted to the ICU. She developed a severe multiple organ failure within 12 hours. Recovery took 54 days. The discussion is focussed on risk factors for the use of the LMA, adequate intraoperative monitoring, possible disadvantages of the applied anaesthetic technique and initial treatment after aspiration.

Aged↗
PubMed2002

[Patient selection criteria for single-sided or minimal invasive operative procedures in primary hyperparathyroidism (pHPT)].

In 56 postoperative patients with primary hyperparathyroidism we analysed retrospectively whether a single-sided or minimal invasive operative procedure could have been utilized. Additionally the sensitivity of (99m)TC-Sestamibiscintiscanning and ultrasound of the neck region was assessed. Single gland disease was found in 49 patients, 6 patients had primary multiglandular disease and one patient revealed a double adenoma. The overall sensitivity of (99m)TC-Sestamibiscintiscanning and ultrasound was found to be 78 % and 53 % respectively. In 46 patients the operation would have been started minimal invasive, in 7 of these patients a conversion to bilateral exploration would have been necessary because of four gland hyperplasia, double adenoma or misleading preoperative localisation. In 39 patients a successful minimal invasive procedure would have been possible. A primary bilateral exploration would have been necessary in 10 patients because of either coexisting goiter or questionable localisation of the pathological altered gland. Since sensitivity of localisation diagnostics is low with regard to multiglandular disease, parathyroid hormone should be monitored intraoperatively whenever minimal invasive operative procedures are performed.

Adenoma↗
PubMed2003

[Point of care (POC) monitoring in anesthesia and intensive care--an overview of available POC systems].

There is an increasing trend to have data rapidly ready at the patient's bedside. The general principle behind point-of-care (POC) testing is that "faster is better" ('from vein to brain'). The entire process for laboratory testing includes withdrawal of blood into special (pre-labelled) tubes, transportation of the sample to the central laboratory where the plasma is separated from the blood cells by centrifugation, carefully pippeting of a defined volume of plasma that is placed in the analyzer. POC instruments provide us with the potential to do old things in new ways. With the help of portable POC analyzers a variety of laboratory parameters including coagulation parameters, blood gas analysis, electrolytes, markers of organ function can be measured next to the patient's bed thus significantly shorting turnaround-time (TAT). Cost analyses of new monitoring devices are necessary in today's climate of cost savings. It is important to capture all costs and not only costs of the test kits. Direct costs (e. g. test cartridges, costs for the analyzers, cost for quality control) may constitute only a small percentage of the true costs. Hidden costs consist of overhead costs (e. g. transportation) and the consequences of delayed results. The present overview summarizes the available POC systems in Germany and may serve as a decision maker for those who are interested in introducing POC monitoring systems.

Anesthesia↗
PubMed1991

[The effects of halothane and nitrous oxide on transcranial magnetic evoked potentials].

The influence of volatile anaesthetic agents on transcranial magnetic motor evoked potentials (TMEP) is not known. The effect of halothane and nitrous oxide on TMEP as recorded from hand was studied in 10 patients undergoing lumbar spinal surgery. In no case were the TMEP documented when halothane and nitrous oxide were administered. After withdrawal of both agents it took up to 29 minutes until the TMEP reappeared. It is concluded that intraoperative monitoring of TMEP is not possible if halothane and nitrous oxide are administered.

Anesthesia, Inhalation↗
PubMed1980

Ophthalmodynamic studies in kinking of the internal carotid artery. Surgical implications.

In 6 patients with kinking of the internal carotid artery and 10 healthy volunteers ophthalmodynamographic studies were performed. Sideward head bending in the patients caused major ipsilateral decrease of internal carotid flow as did forward flexion on both sides. This effect was minimal in healthy humans. Intraoperative monitoring by the same method showed instant improvement of flow dynamics after kink resection and end-to-end anastomosis.

Adult↗
PubMed1998

[Concentration-dependent changes in the latency and amplitude of somatosensory-evoked potentials by desflurane, isoflurane and sevoflurane].

PURPOSE: Comparison of the influence of desflurane, isoflurane, and sevoflurane on the parameters of cortical somatosensory evoked potentials (SEP). METHODS: A total of 41 patients were randomly allocated to either the isoflurane, desflurane or sevoflurane group. Following induction with propofol and intubation, concentration of the volatile anaesthetic was kept constant at 1.3, 1.0, and 0.7 MAC for 15 minutes each in randomised sequences. No opioids or N2O were used. Cortical somatosensory evoked potentials were recorded following median nerve stimulation at the wrist with 1.5 times motor threshold current. SEP were evaluated for latencies of peak N20 and P25 as well as peak-to-peak amplitude N20P25. Measurements at the end of the 15 minute equilibration intervals were compared by analysis of variance for repeated measurements. Latencies and the logarithm of the amplitudes were assumed to be normally distributed. RESULTS: SEP could be recorded in all patients and at all concentrations. Latency of cortical SEP increased with anaesthetic concentration in a linear manner. No differences in latency increase were found between the three anaesthetics (ANOVA). In contrast, the decrease in amplitude with increasing anaesthetic concentration was non-linear. It was large from control to 0.7 MAC, but small in the range between 0.7 and 1.3 MAC. Amplitude reduction was larger with isoflurane than with sevoflurane or desflurane. CONCLUSION: 1) Sevoflurane and desflurane are better suited for anaesthetic management during intraoperative electrophysiological monitoring than isoflurane, because SEP amplitudes are better preserved. 2) SEP amplitude is less altered by changing anaesthetic concentrations in the concentration range from 0.7 to 1.3 MAC than SEP latency.

Adult↗