Is post-sternotomy percutaneous dilatational tracheostomy a predictor for sternal wound infections?

OBJECTIVE: Early post-sternotomy tracheostomy is not infrequently considered in this era of percutaneous tracheostomy. There is, however, some controversy about its association with sternal wound infections. METHODS: Consecutive patients who had percutaneous tracheostomy following median sternotomy for cardiac operation at our institution from March 1998 through January 2007 were studied, and compared to contemporaneous patients. We identified risk factors for tracheostomy, and investigated the association between percutaneous tracheostomy and deep sternal wound infection (mediastinitis) by multivariate analysis. RESULTS: Of 7002 patients, 100 (1.4%) had percutaneous tracheostomy. The procedure-specific rates were: 8.6% for aortic surgery, 2.7% for mitral valve repair/replacement (MVR), 1.1% for aortic valve replacement (AVR), and 0.9% for coronary artery bypass grafting (CABG). Tracheostomy patients differed vastly from other patients on account of older age, severe symptoms, preoperative support, lower ejection fraction, more comorbidities, more non-elective and complex operations and higher EuroScore. Risk factors for tracheostomy were New York Heart Association class III/IV (OR 6.01, 95% CI 2.28-16.23, p<0.0001), chronic obstructive pulmonary disease (OR 1.84, 95% CI 1.01-3.37, p=0.05), preoperative renal failure (OR 3.57, 95% CI 1.41-9.01, p=0.007), prior stroke (OR 3.08, 95% CI 1.75-5.42, p<0.0001), ejection fraction<0.30% (OR 2.73, 95% CI 1.23-6.07, p=0.01), and bypass time (OR 1.008, 95% CI 1.004-1.012, p<0.0001). The incidences of deep (9% vs 0.7%, p<0.0001) and superficial sternal infections (31% vs 6.5%, p<0.0001) were significantly higher among tracheostomy patients. Multivariate analysis identified percutaneous tracheostomy as a predictor for deep sternal wound infection (OR 3.22, 95% CI 1.14-9.31, p<0.0001). CONCLUSIONS: Tracheostomy, often performed in high-risk patients, may further complicate recovery with sternal wound infections, including mediastinitis, therefore, patients and timing should be carefully selected for post-sternotomy tracheostomy.     

Central neural pathway mediating splanchnic osmosensation

To determine the central neural pathway which carries splanchnic osmosensory information to vasopressin (AVP) neurons in the hypothalamus, bilateral electrolytic lesions were placed in the ascending catecholaminergic fiber bundle, the locus coeruleus (LC), the locus subcoeruleus (subLC), the lateral parabrachial nucleus (LPB), the caudal periaqueductal gray (PAG) and the median preoptic nucleus (MPO). Six and seven days later, plasma AVP levels, plasma osmolality, mean arterial pressure and heart rate were measured following gastric infusion of hypertonic (598 mosm/kg; 2ml/4min) or isotonic (290 mosm/kg) saline in conscious rats with indwelling tail artery catheters and nasogastric tubes. The most effective pontine lesions, which were located in the ventral locus subcoeruleus (vsubLC) approximately 1.0 mm below the LC, decreased the AVP response to hypertonic gastric infusion by 59.7% (P < 0.05) as compared to sham-lesioned controls. In addition, unilateral vsubLC lesions dramatically reduced the catecholamine innervation of the ipsilateral paraventricular nucleus (PVN), as qualitatively determined with dopamine β-hydroxylase immunocytochemistry, suggesting that a pathway ascending with catecholaminergic fibers was disrupted. Lesions of the MPO were also very effective, decreasing the AVP response to hypertonic saline infusion by 60.3% (P < 0.05), suggesting that the MPO is an integral relay center in this pathway. On the other hand, LC, LPB and PAG lesions were ineffective. Systemic plasma osmolality or cardiovascular factors did not mediate the AVP response. These results demonstrate, for the first time, that splachnic osmotic information is transmitted to the hypothalamus via pathways within the ascending catecholaminergic fiber bundles, the MPO is a relay center where peripheral and central osmotic information may be integrated, and the LC, LPB and PAG are not part of the splanchnic osmotic pathway.     

Median Nerve Stimulation in a Patient with Complex Regional Pain Syndrome Type II

A 54-year-old man experienced injury to the second finger of his left hand due to damage from a paintball gun shot 8 years prior, and the metacarpo-phalangeal joint was amputated. He gradually developed mechanical allodynia and burning pain, and there were trophic changes of the thenar muscle and he reported coldness on his left hand and forearm. A neuroma was found on the left second common digital nerve and was removed, but his symptoms continued despite various conservative treatments including a morphine infusion pump on his left arm. We therefore attempted median nerve stimulation to treat the chronic pain. The procedure was performed in two stages. The first procedure involved exposure of the median nerve on the mid-humerus level and placing of the electrode. The trial stimulation lasted for 7 days and the patient''s symptoms improved. The second procedure involved implantation of a pulse generator on the left subclavian area. The mechanical allodynia and pain relief score, based on the visual analogue scale, decreased from 9 before surgery to 4 after surgery. The patient''s activity improved markedly, but trophic changes and vasomotor symptom recovered only moderately. In conclusion, median nerve stimulation can improve chronic pain from complex regional pain syndrome type II.     

Lipofibromatous hamartoma of the median nerve: A case report and review of the literature

A case of lipofibromatous hamartoma of the median nerve in an adult is described in this article. A 33-year-old male presented with tingling, numbness and swelling in the palm of the left non dominant hand that had been present for a few months. Examination revealed that there was fullness in the volar aspect of the wrist and in the inter-thenar area. Another mass was present at the base of the index finger, which appeared to be involving subcutaneous tissues. The clinical diagnosis was carpal tunnel syndrome due to a space occupying tumor mass in the carpal tunnel. On exploration of the carpal tunnel, a large median nerve was seen 4 cm proximal to the wrist crease line and extending distally until it divided into its branches. Another mass was present at the base of the index finger, which was adherent to the skin. The radial digital nerve of the index finger was normal in size. For the enlarged nerve, an epineurotomy was performed and a biopsy was taken. Another biopsy was taken from the distal mass. His postoperative period was uneventful. In July 2004, at the end of 5 years, the patient had no symptoms and the size of the tumor had not increased.     

Augmentation mentoplasty: A critical analysis

An evaluation of the senior author's mentoplasty technique by use of inorganic silicone and acrylic implants is presented, encompassing 16 years of experience. The evaluation was chiefly concerned with the silicone implant and long-term followup observations of its survival and some of its extrusions and complications.     

羟考酮用于血管减压手术术终镇痛衔接的半数有效剂量

目的通过序贯法测定羟考酮用于显微血管减压手术术终镇痛衔接的半数有效剂量(Median effective dose,ED_(50))。方法选择2017年6—10月在全麻下行经乙状窦入路显微血管减压手术的面肌痉挛患者23例,男5例,女18例,年龄18~64岁,BMI 18~24kg/m2,ASAⅠ或Ⅱ级。手术结束前30min给予羟考酮,手术结束后连接相同配方的镇痛泵。根据序贯法设定浓度,当出现第7个交叉点时终止试验。术后30min患者镇痛口述分级(verbal rating score,VRS)评分1分为阴性。结果 Dixon-Mood法计算羟考酮ED_(50)为0.054mg/kg(95%CI 0.053~0.056mg/kg);Probit回归模型计算为0.054mg/kg(95%CI 0.030~0.077mg/kg)。结论羟考酮用于显微血管减压手术术终镇痛衔接的ED50为0.054mg/kg。     

改良胸骨正中切口

胸骨正中切口是心脏直视手术的常规入路,但切口上端的手术瘢痕常影响病人的美容。101例心脏直视手术采用上端弧形的改良胸骨正中切开术。我们的技术不同于经乳房下皮肤切口的胸骨正中切开术,这种入路能获得适当的显露,操作简便,美容效果良好。     

正中弓状韧带综合征合并胰十二指肠动脉瘤1例

正患者女,32岁,因"体检B超发现腹腔动脉瘤"就诊。患者无腹痛等症状,体格检查及实验室检查均未见异常。腹部增强CT提示肠系膜上动脉分支动脉瘤,大小约20mm×17mm,合并腹腔干起始处重度狭窄(图1A、1B)。腹腔动脉造影(图1C、1D)示胰十二指肠下动脉瘤,肠系膜上动脉代偿增粗,产生侧支