Current Issue : April - June Volume : 2012 Issue Number : 2 Articles : 8 Articles
Fontan and Baudet described in 1971 the separation of the pulmonary and systemic circulations resulting in univentricular\r\nphysiology. The evolution of the Fontan procedure, most notably the substitution of right atrial-to-pulmonary artery anastomosis\r\nwith cavopulmonary connections, resulted in significantly improved late outcomes. Many patients survive well into adulthood\r\nand are able to lead productive lives.While ideally under medical care at specialized centers for adult congenital cardiac pathology,\r\nthese patients may present to the outside hospitals for emergency surgery, electrophysiologic interventions, and pregnancy. This\r\npresentation presents a ââ?¬Å?train of thought,ââ?¬Â linking the TEE images to the perioperative physiologic considerations faced by an\r\nanesthesiologist caring for a patient with Fontan circulation in the perioperative settings. Relevant effects of mechanical ventilation\r\non pulmonary vascular resistance, pulmonary blood flow and cardiac preload, presence of coagulopathy and thromboembolic\r\npotential, danger of abrupt changes of systemic vascular resistance and systemic venous return are discussed....
Background : Postherpetic neuralgia (PHN) is a complication of acute herpes zoster, which is emerging as a\r\npreferred clinical trial model for chronic neuropathic pain. Although there are published metaanalyses\r\nof analgesic therapy in PHN, and neuropathic pain in general, the evidence base has\r\nbeen substantially enhanced by the recent publication of several major trials. Therefore, we\r\nhave conducted a systematic review and meta-analysis for both efficacy and adverse events of\r\nanalgesic therapy for PHN.\r\nMethods and Findings : We systematically searched databases (MEDLINE 1966ââ?¬â??2004, EMBASE 1988ââ?¬â??2004, CINAHL\r\n1982ââ?¬â??2002, and PubMed [29 October 2004]) for trials of PHN. We also searched references of\r\nretrieved studies and review articles for further trials. We included trials that examined adult\r\npatients with PHN of greater duration than 3 mo, that were blinded, randomised, and had at\r\nleast one measure of pain outcome. Dichotomous pain outcome data were extracted for 50%\r\ndecrease in baseline pain using a hierarchy of pain/pain-relief measurement tools. Where\r\navailable, dichotomous data were also collected for adverse events. Calculated estimates of\r\nefficacy included relative benefit and number needed to treat.\r\nOf 62 studies identified, 35 were randomised controlled trials. Of these, 31 were placebo\r\ncontrolled and suitable for meta-analysis, from which it was possible to extract dichotomous\r\nefficacy outcome data from 25.\r\nThis meta-analysis revealed that there is evidence to support the use of the following orally\r\nadministered therapies: tricyclic antidepressants, ââ?¬Ë?ââ?¬Ë?strongââ?¬â?¢Ã¢â?¬â?¢ opioids, gabapentin, tramadol, and\r\npregabalin. Topical therapies associated with efficacy were lidocaine 5% patch and capsaicin.\r\nFinally, a single study of spinal intrathecal administration of lidocaine and methyl prednisolone\r\ndemonstrated efficacy, although this has yet to be replicated.\r\nData suggest that the following therapies are not associated with efficacy in PHN: certain\r\nNMDA receptor antagonists (e.g., oral memantine, oral dextromethorphan, intravenous\r\nketamine), codeine, ibuprofen, lorazepam, certain 5HT1 receptor agonists, and acyclovir.\r\nTopical administration of benzydamine, diclofenac/diethyl ether, and vincristine (iontophoresis)\r\nare similarly not associated with efficacy, nor are intrathecal administration of lidocaine alone or\r\nepidural administration of lidocaine and methylprednisolone, intravenous therapy with\r\nlidocaine, subcutaneous injection of Cronassial, or acupuncture. However, many of the trials\r\nthat demonstrated a lack of efficacy represented comparatively low numbers of patient\r\nepisodes or were single-dose studies, so it may be appropriate to regard such interventions as\r\nââ?¬Ë?ââ?¬Ë?not yet adequately testedââ?¬â?¢Ã¢â?¬â?¢ rather than demonstrating ââ?¬Ë?ââ?¬Ë?no evidence of efficacy.ââ?¬â?¢Ã¢â?¬â?¢ Topical\r\naspirin/diethyl ether has not been adequately tested.\r\nConclusion : The evidence base supports the oral use of tricyclic antidepressants, certain opioids, and\r\ngabapentinoids in PHN. Topical therapy with lidocaine patches and capsaicin is similarly\r\nsupported. Intrathecal administration of methylprednisolone appears to be associated with\r\nhigh efficacy, but its safety requires further evaluation...
The transversus abdominis plane (TAP) block is a relatively new regional anesthesia technique that provides analgesia to the\r\nparietal peritoneum as well as the skin and muscles of the anterior abdominal wall. It has a high margin of safety and is technically\r\nsimple to perform, especially under ultrasound guidance. A growing body of evidence supports the use of TAP blocks for a variety\r\nof abdominal procedures, yet, widespread adoption of this therapeutic adjunct has been slow. In part, this may be related to the\r\nlimited sources for anesthesiologists to develop an appreciation for its sound anatomical basis and the versatility of its clinical\r\napplication. As such, we provide a brief historical perspective on the TAP block, describe relevant anatomy, review current\r\ntechniques, discuss pharmacologic considerations, and summarize the existing literature regarding its clinical utility with an\r\nemphasis on recently published studies that have not been included in other systematic reviews or meta-analyses....
Lower limb muscles recover faster than upper limb muscles following administration of nondepolarizing neuromuscular relaxants\r\nuntil the train-of-four ratio (TOFR) reached 0.7. However, no study has been conducted to evaluate the recovery time of the\r\nflexor hallucis brevis muscle (FHBM), up to a TOFR of 0.9, which indicates satisfactory recovery of neuromuscular blockade. The\r\naim of this study was to determine electromyographically the relationship between the TOFRs of the FHBM and the first dorsal\r\ninterosseous muscle (FDIM), following 0.1 mg/kg of vecuronium. Eighteen patients were enrolled in this study. Electromyography\r\nof the FDIM and the FHBM was monitored. Onset times and recovery times to TOFRs of 0.7 and 0.9 of both muscles after\r\nadministration of vecuronium were measured. The onset time in the FDIM was not different from that in the FHBM (P = 0.10).\r\nRecovery time to TOFR 0.7 was significantly faster in the FHBM than in the FDIM (P <0.013). There was no significant difference\r\nin the meantime to reach TOFR 0.9 between the FDIM and the FHBM (P = 0.11). There is no clinical importance in the difference\r\nof neuromuscular recovery between the FHBM and the FDIM after TOFR reached 0.9 following administration of vecuronium....
Education and training in advanced airway management as part of an anesthesiology residency program is necessary to help\r\nresidents attain the status of expert in difficult airway management. The Accreditation Council for Graduate Medical Education\r\n(ACGME) emphasizes that residents in anesthesiology must obtain significant experience with a broad spectrum of airway\r\nmanagement techniques. However, there is no specific number required as aminimumclinical experience that should be obtained\r\nin order to ensure competency. We have developed a curriculum for a new Advanced Airway Techniques rotation. This rotation\r\nis supplemented with a hands-on Difficult AirwayWorkshop.We describe here this comprehensive advanced airway management\r\neducational program at our institution. Future studies will focus on determining if education in advanced airway management\r\nresults in a decrease in airway related morbidity and mortality and overall better patients� outcome during difficult airway\r\nmanagement....
Background: There is a growing concern of the potential injurious role of ventilatory over-distention in patients\r\nwithout lung injury. No formal guidelines exist for intraoperative ventilation settings, but the use of tidal volumes\r\n(VT) under 10 mL/kg predicted body weight (PBW) has been recommended in healthy patients. We explored the\r\nincidence and risk factors for receiving large tidal volumes (VT > 10 mL/kg PBW).\r\nMethods: We performed a cross-sectional analysis of our prospectively collected perioperative electronic database\r\nfor current intraoperative ventilation practices and risk factors for receiving large tidal volumes (VT > 10 mL/kg\r\nPBW). We included all adults undergoing prolonged (= 4 h) elective abdominal surgery and collected\r\ndemographic, preoperative (comorbidities), intraoperative (i.e. ventilatory settings, fluid administration) and\r\npostoperative (outcomes) information. We compared patients receiving exhaled tidal volumes > 10 mL/kg PBW\r\nwith those that received 8-10 or < 8 mL/kg PBW with univariate and logistic regression analyses.\r\nResults: Ventilatory settings were non-uniform in the 429 adults included in the analysis. 17.5% of all patients\r\nreceived VT > 10 mL/kg PBW. 34.0% of all obese patients (body mass index, BMI, = 30), 51% of all patients with a\r\nheight < 165 cm, and 34.6% of all female patients received VT > 10 mL/kg PBW.\r\nConclusions: Ventilation with VT > 10 mL/kg PBW is still common, although poor correlation with PBW suggests it\r\nmay be unintentional. BMI = 30, female gender and height < 165 cm may predispose to receive large tidal\r\nvolumes during general anesthesia. Further awareness of patients� height and PBW is needed to improve\r\nintraoperative ventilation practices. The impact on clinical outcome needs confirmation....
Secretory human prostatic acid phosphatase (hPAP) is glycosylated at three asparagine residues (N62, N188, N301) and has\r\npotent antinociceptive effects when administered to mice. Currently, it is unknown if these N-linked residues are required\r\nfor hPAP protein stability and activity in vitro or in animal models of chronic pain. Here, we expressed wild-type hPAP and a\r\nseries of Asn to Gln point mutations in the yeast Pichia pastoris X33 then analyzed protein levels and enzyme activity in cell\r\nlysates and in conditioned media. Pichia secreted wild-type recombinant (r)-hPAP into the media (6ââ?¬â??7 mg protein/L). This\r\nprotein was as active as native hPAP in biochemical assays and in mouse models of inflammatory pain and neuropathic\r\npain. In contrast, the N62Q and N188Q single mutants and the N62Q, N188Q double mutant were expressed at lower levels\r\nand were less active than wild-type r-hPAP. The purified N62Q, N188Q double mutant protein was also 1.9 fold less active in\r\nvivo. The N301Q mutant was not expressed, suggesting a critical role for this residue in protein stability. To explicitly test the\r\nimportance of secretion, a construct lacking the signal peptide of hPAP was expressed in Pichia and assayed. This ââ?¬Ë?ââ?¬Ë?cellularââ?¬â?¢Ã¢â?¬â?¢\r\nconstruct was not expressed at levels detectable by western blotting. Taken together, these data indicate that secretion and\r\npost-translational carbohydrate modifications are required for PAP protein stability and catalytic activity. Moreover, our\r\nfindings indicate that recombinant hPAP can be produced in Pichiaââ?¬â?a yeast strain that is used to generate biologics for\r\ntherapeutic purposes....
Objective. Unilateral sensory and motor blockade is known to occur with epidural anesthesia but is rarely reported in children. The\r\ndifferential diagnosis should include the presence of a midline epidural septum. Case Report. We describe a case of a 16-year-old\r\nadolescent who developed repeated complete unilateral extensive epidural sensory and motor blockade with Horner�s syndrome\r\nafter thoracic epidural catheter placement. This unusual presentation of complete hemibody neural blockade has not been reported\r\nin the pediatric population.Maneuvers to improve contralateral uniform neural blockade were unsuccessful. An epidurogram was\r\nperformed to ascertain the correct location of the catheter within the epidural space and presence of sagittal compartmentalization.\r\nConclusion. This case report highlights a less frequently reported reason for unilateral sensory and motor blockade with epidural\r\nanesthesia in children. The presence of a midline epidural septum should be considered in the differential diagnosis of unilateral\r\nepidural blockade....
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