Acute normovolaemic haemodilution decreases postoperative allogeneic blood transfusion after total knee replacement

We hypothesized that the success of postoperative blood conservation after acute normovolaemic haemodilution (NVHD) is influenced by the extent of intraoperative bleeding and surgical trauma, and the timing of autologous blood transfusion. As total knee replacement is associated with minimal intraoperative but extensive postoperative blood loss, this procedure is ideally suited to acute NVHD. Therefore, to test our hypothesis, 30 patients undergoing elective total knee replacement were enrolled in a prospective, randomized, controlled study. In groups NVHD-2 and NVHD-6, before induction of anaesthesia patients were bled to a target packed cell volume (PCV) of 28-30%, and in the post-anaesthesia care unit autologous blood was transfused over a 2-h period terminating after operation at 2 and 6 h, respectively. In the control group, NVHD was not performed. After operation, platelets, fibrinogen, prothrombin and partial thromboplastin time, and liver function, urea and electrolytes were measured and compared with preoperative baseline values. Significantly (P < 0.024) more allogeneic blood was transfused in the control group (21 u.) compared with either group NVHD-2 (7 u.) or group NVHD-6 (5 u.). In the control group, despite the allogeneic blood transfusion, postoperative PCV decreased until day 4 after operation. Coagulation profile, liver function and urea and electrolytes concentrations were unaffected by the method of treatment. We conclude that for total knee replacement, acute NVHD is an effective blood conservation strategy. However, there was no difference in allogeneic blood administration between the two NVHD groups. Coagulation and liver function, and urea and electrolyte concentrations were unaffected by treatment.      

Effect of spinal versus general anesthesia on bladder compliance and intraabdominal pressure during transurethral procedures.

STUDY OBJECTIVE: To evaluate the influence of spinal versus general anesthesia on bladder compliance and intraabdominal pressure in elderly males undergoing elective transurethral resection of the prostate. DESIGN: Prospective, randomized, open-label study. SETTING: Teaching hospital. PATIENTS: 21 ASA physical status I, II, and III patients at least 18 years of age, undergoing transurethral surgery. INTERVENTIONS: According to a computer-generated randomization schedule, patients were allocated to one of two groups. In Group Spinal (S), 10 mg of hyperbaric tetracaine was administered intrathecally. In Group General Anesthesia (GA), patients received, fentanyl intravenous (i.v. 1 to 2 micrograms/kg and propofol i.v. 1.0 to 2.0 mg/kg for induction of anesthesia. Thereafter, a laryngeal mask airway was inserted and, with spontaneous ventilation, anesthesia was maintained by administering isoflurane (end-tidal 0.7% to 1.2%) and 70% nitrous oxide (N2O) in oxygen. Intraabdominal pressure and bladder compliance were recorded prior to the induction of anesthesia and immediately before the onset of the surgical procedure. MEASUREMENTS AND MAIN RESULTS: The two groups were demographically comparable. In Group S, mean bladder compliance was significantly (p = 0.003) higher and mean intraabdominal pressure significantly lower (p = 0.007) when compared to baseline preanesthetic values. In Group GA, mean intraabdominal pressure significantly (p = 0.006) decreased when compared to baseline preanesthetic recordings. Following the induction of general anesthesia, a small change in bladder compliance was noted. However, statistical significance was not reached. Data were analyzed and compared using Student's t-test (p < 0.05 was considered statistically significant). CONCLUSION: Both spinal and general anesthesia induced a significant decrease in intraabdominal pressure. While both techniques were associated with an increase in bladder compliance, statistical significance was demonstrated only in the spinal anesthesia treatment group.     

Disseminated intravascular coagulopathy and adult respiratory distress syndrome: life-threatening complications of hysteroscopy.

A 23-year-old, healthy woman underwent hysteroscopy during which Hyskon solution was injected into the uterine cavity. Soon afterward she developed a bleeding coagulopathy followed by acute respiratory insufficiency and pulmonary edema, necessitating endotracheal intubation and artificial ventilation with positive end-expiratory pressure. This rare complication of hysteroscopy was most probably due to the injection of Hyskon solution.     

Hepatic infarction in preeclampsia as part of the HELLP syndrome: CT appearance

We describe the computed tomographic (CT) findings of hepatic infarctions in two preeclamptic pregnant women. These infarcts were part of the HELLP syndrome (hemolysis, elevated liver function tests, and low platelets count). In both cases, CT disclosed features characteristic of multiple nonenhancing, low-attenuation, peripheral lesions with vessels coursing through and a mottled appearance. The recognition of such CT findings in liver disease associated with preeclampsia can establish the correct diagnosis.     

Anaesthesia for caesarean delivery: low-dose epidural bupivacaine plus fentanyl

To determine the acceptability of epidural bupivacaine-induced sixth thoracic (T6) sensory blockade and the analgesic efficacy of epidural fentanyl 50 microg, 24 parturients undergoing elective caesarean section were given a test dose of lidocaine 60 mg plus epinephrine followed by 10 ml of either 0.5 % bupivacaine (control group) or 0.5 % bupivacaine plus 50 microg fentanyl (fentanyl group) in a randomized double-blind manner. Fifteen minutes later loss of pinprick sensation was determined. Additional local anaesthetic was titrated to achieve T6 sensory blockade. Intraoperative pain intensity was assessed using a 10 cm visual analogue scale (VAS); total dose of bupivacaine and need for i.v. rescue fentanyl were recorded. The incidence of intraoperative respiratory depression, nausea, vomiting and pruritus were documented. Mean (+/- SD) volume of bupivacaine was 14.1 +/- 3.05 ml versus 13 +/- 1.48 ml for the control and fentanyl groups respectively. The most severe intraoperative VAS for pain was significantly (P=0.023) lower in the fentanyl group (0.4 +/- 0.08 cm) than in the control group (3.1 +/- 0.3 cm). Rescue fentanyl was administered in 40% and 0% of patients in the control and fentanyl groups respectively. The incidence of side-effects was unaffected by treatment group. Apgar scores were similar in the two groups. We conclude that following administration of 10-15 ml 0.5% bupivacaine plus fentanyl 50 microg, T6 sensory blockade is associated with good intraoperative analgesia without obvious maternal or neonatal respiratory depression.     

The induction, maintenance, and recovery characteristics of spinal versus general anesthesia in elderly patients

Study Objective: To compare the induction and recovery profiles of three combinations of general anesthesia when used as an alternative to spinal anesthesia for elderly patients.

Design: Randomized, prospective, open-label study.

Setting: Large referral hospital.

Patients: 100 [ASA physical status I, II, and III] patients over 60 years of age undergoing brief transurethral surgery.

Interventions: In Groups Propofol-Propofol (P-P), Propofol-Isoflurane (P-I), and Propofol-Desflurane (P-D), anesthesia was induced with fentanyl (1 to 2 μg/kg IV) and propofol (1.0 to 2.0 mg/kg IV) and maintained with 70% nitrous oxide in oxygen and either a propofol infusion (75 to 150 μg/kg/min) or isoflurane (end-tidal 0.7% to 1.2%) or desflurane (end-tidal 1% to 4%), respectively. After induction, a laryngeal mask airway was placed and spontaneous ventilation was maintained. In Group Spinal (S), 1.5 ml 4% lidocaine (60 mg), in an equal volume of 10% dextrose, was administered intrathecally.

Measurements and Main Results: Induction and recovery characteristics were compared. Induction with propofol was technically easier and significantly (medp < 0.0001) faster (4.6 ± 1.7 min, 4.7 ± 2.2 min, and 3.8 ± 1.4 min for Groups P-P, P-I, and P-D, respectively) than induction of spinal anesthesia (9.3 ± 3.4 min). During the induction period, mean arterial blood pressure and heart rate were significantly higher in Group S. Emergence, extubation, and orientation times were similar among the general anesthesia treatment groups. In Group S, patient-generated pain scores were lower (p < 0.05) and recovery room admission longer (p < 0.001). Time to return to baseline digit symbol substitution test (DSST) scores was marginally improved in Groups P-P and P-D when compared to Group P-I. Postoperative nausea, sleepiness, anxiety, and coordination were unaffected by the treatment modality.

Conclusion: General anesthesia with propofol and desflurane facilitates shorter induction and recovery times without adversely affecting patient comfort. Therefore, this technique may be preferable to spinal anesthesia for elderly patients undergoing short transurethral surgical procedures.     

Combined morphologic and fluorescence in situ hybridization analysis of voided urine samples for the detection and follow‐up of bladder cancer in patients with benign urine cytology

BACKGROUND.

Bladder cancer is among the 5 most common malignancies worldwide. Patients with bladder cancer are closely followed with periodic cystoscopies and urine cytology analyses due to the significant risk of tumor recurrence. The UroVysion fluorescence in situ hybridization (FISH) test demonstrated higher sensitivity over urine cytology in detecting bladder cancer by most comparative studies.

METHODS.

In the current study, the diagnostic usefulness of a combined cytology and FISH analysis approach was tested using the Duet automatic scanning system in patients with benign urine cytology who were being monitored for recurrent urothelial carcinoma or being assessed for various urologic symptoms.

RESULTS.

By combining the benefits of conventional cytology with molecular diagnostics, a more sensitive detection of bladder cancer was attained. All patients who had positive cystoscopy concomitantly with urine sampling were detected by combined analysis. Additional patients that developed transitional cell carcinoma during a follow‐up period of 24 months had a previous positive result on combined analysis. Only 2 patients with a negative combined analysis result presented with late disease recurrence (20 months and 22 months, respectively, after the negative test). Therefore, negative combined analysis was found to be predictive of a lack of disease recurrence for at least 12 months. In this timeframe, the overall sensitivity, specificity, negative predictive value (NPV), and positive predictive values of the combined analysis test were 100%, 65%, 100%, and 44%, respectively.

CONCLUSIONS.

Given the absolute sensitivity and NPV of the combined analysis test, the management of patients with a negative combined analysis result might be revised and allow for more flexible assessment and management of bladder cancer patients relying more on urine bound tests. Cancer (Cancer Cytopathol) 2007. © 2007 American Cancer Society.