“Green anesthesia” in the “Green Journal”

Canadian Journal of Anesthesia/Journal canadien d'anesthésie -     

Under “real world” conditions, desflurane increases drug cost without speeding discharge after short ambulatory anesthesia compared to isoflurane

PURPOSE: To compare the measured "real world" perioperative drug cost and recovery associated with desflurane- and isoflurane-based anesthesia in short (less than one hour) ambulatory surgery. METHODS: We conducted a prospective, randomized, blinded trial with patients undergoing arthroscopic meniscectomy under general anesthesia. Following iv induction, patients received either isoflurane (group I; n = 25) or desflurane (group D; n = 20) for maintenance. The primary outcome variable was total perioperative drug cost per patient in Canadian dollars. Secondary outcome variables included volatile agent consumption and cost, adjuvant anesthetic and postanesthesia care unit (PACU) drug cost, readiness for PACU discharge, and incidence of adverse events. RESULTS: Total perioperative drug cost per patient was 14.58 +/- 6.83 Canadian dollars (mean +/- standard deviation) for group I, and 21.47 +/- 5.18 Canadian dollars for group D (P < 0.001). Isoflurane consumption per patient was 6.0 +/- 3.0 mL compared to 18.6 +/- 7.7 mL for desflurane (P < 0.0001); corresponding costs were 0.83 +/- 0.42 Canadian dollars vs 7.61 +/- 3.15 Canadian dollars (P < 0.0001). There were no differences in adjuvant anesthetic or PACU drug cost. All but one patient from each group were deemed ready for PACU discharge at 15 min postoperatively (Aldrete score >or= 9). One patient in group D experienced postoperative nausea. No other adverse events were noted. CONCLUSIONS: Measured total perioperative drug cost for a short ambulatory procedure (less than one hour) under general anesthesia was higher when desflurane rather than isoflurane was used for maintenance, essentially due to volatile agent cost. Desflurane use did not translate into faster PACU discharge under "real world" conditions.     

The “old” 15 mm renal stone size limit for RIRS remains a clinically significant threshold size

Purpose

To investigate the performance of retrograde intrarenal surgery (RIRS) for the 1–2 cm renal stone size range in comparison to smaller stones.

Materials and methods

From a data base of 3000 ureteroscopies between 2004 and 2014, 635 consecutive patients underwent RIRS for renal stones. Patients were divided to three groups according to their renal stone size (<10, 10–15, 15–20 mm). Preoperative, operative, stone free rate (SFR) and follow-up data were analyzed and compared.

Results

The SFR for the three groups was 94.1, 90.1 and 85%, respectively. Patients with renal stone size above 15 mm had a statistically significantly lower SFR. The efficiency quotient calculated for stones larger and smaller than 15 mm was 83.9 vs. 91.8%, respectively (p < 0.01). The mean operative time and hospital stay were longer for patients with renal stones larger than 15 mm (73.6 ± 29.9 vs. 53 ± 19.4 min, p < 0.01 and 2.2 ± 2 vs. 1.8 ± 1.8 days, p = 0.031, respectively). Moreover, the complication rate was almost two times higher (10 vs 5.4%, p = 0.08). Concomitant ureteral stones and older age were independent predictors of failure in the large stone group.

Conclusions

While the overall SFR following RIRS for renal stones up to 2 cm is generally high, the SFR for 15–20 mm stones is significantly lower, with a longer operating time and hospital stay, and a higher complication rate.

     

Repeated spinal anesthesia in a tetraparetic patient with Guillain-Barré syndrome

A 78 year old man with tetraparesis, reduced forced vital capacity, and neurogenic bladder dysfunction due to Guillain-Barré syndrome was admitted for elective transurethral prostate resection and percutaneous lithotripsy of a bladder stone. On the sixth postoperative day, he was readmitted for emergency evacuation of a clot in the bladder. Both operations were performed with spinal anesthesia (hyperbaric bupivacaine + fentanyl) without neurologic sequelae.     

“POMELO PROJECT” - a simple and low cost simulator for harvesting skin graft by plastic surgery residents

BackgroundHarvesting partial thickness skin grafts is an important technical skill the training plastic surgeon is required to hone. Historically accomplished via manual dermatome (Humby's knife) or the modern day electric dermatome.ObjectivePresenting a means of practicing the use of Humby’s knife for novice surgeons.Methods15 plastic surgeons comprising 8 seniors and 7 residents, in a single tertiary center participated. Each utilised a Humby knife to harvest 4 skin grafts from a Pomelo. The graft areas were measured via computerised image processing, comparing measures of graft harvest consistency across groups of surgeons.ResultsIn the resident surgeon group, the average relative difference between exact graft area and encompassing area was 0.45, as compared with 0.15 in the Senior surgeon group, indicating a greater degree of inconsistency in graft harvest. Comparisons across groups yielded significant differences per each of the 4 grafts harvested (p < = 0.005).Limitationssingle center and small cohort (inherent to the sparsity of plastic surgeons), marginal statistical evidence.ConclusionsCitrus Maxima (Pomelo) is a useful substrate to instruct and practice the use of Humby knife effectively, allowing novice surgeons to practice the manual manoeuvres required therefore as well as increase confidence in its subsequent operative use.     

Acute respiratory distress syndrome after prolonged hyperbaric oxygen therapy: a case of pulmonary oxygen toxicity?

A 42-year-old patient was admitted to our ICU for severe decompression illness with tetraplegia. He presented an acute respiratory distress syndrome (ARDS), following a very long hyperbaric oxygen therapy (using a US. Navy Treatment Table 7). The ARDS resulted in pulmonary fibrosis, and the patient died despite maximal support in ICU. The risk of pulmonary toxicity of oxygen must be considered when using a prolonged recompression treatment table.     

Clarification on: “Pectoral nerves I block is associated with a significant motor blockade with no dermatomal sensory changes”

Canadian Journal of Anesthesia/Journal canadien d'anesthésie -     

Periorbital ecchymoses during general anesthesia in a patient with primary amyloidosis: a harbinger for bleeding?

Primary amyloidosis is a result of proliferation of a population of plasma cells that leads to an increased secretion of monoclonal immunoglobulins (amyloid). Amyloid protein infiltrates increase capillary fragility. Such capillaries can burst, even after minor stress, resulting in periorbital hemorrhage. We describe a 64-yr-old man with primary amyloidosis who underwent general anesthesia. His eyes were gently closed with tape. Upon removal of the tape bilateral periorbital purpura was noted. All coagulation studies were normal. The periorbital hemorrhage was attributed to amyloidosis-induced capillary fragility.