Acute compartment syndrome. Who is at risk?

We have analysed associated factors in 164 patients with acute compartment syndrome whom we treated over an eight-year period. In 69% there was an associated fracture, about half of which were of the tibial shaft. Most patients were men, usually under 35 years of age. Acute compartment syndrome of the forearm, with associated fracture of the distal end of the radius, was again seen most commonly in young men. Injury to soft tissues, without fracture, was the second most common cause of the syndrome and one-tenth of the patients had a bleeding disorder or were taking anticoagulant drugs. We found that young patients, especially men, were at risk of acute compartment syndrome after injury. When treating such injured patients, the diagnosis should be made early, utilising measurements of tissue pressure.     

Who is at increased risk of aspiration?

Editor—We read with interest Asai's editorial about therisks of pulmonary aspiration,¹ which was precipitated by ourreport of three cases of pulmonary aspiration occurring withthe laryngeal mask airway (LMA®).² Asai commented on thesix factors leading to aspiration (predisposing, patient, operation,anaesthesia, device and variability in the material aspirated)and concluded that we lack sufficient data to make evidence-baseddecisions and need to conduct further research to reduce theseuncertainties. While agreeing with Asai's conclusions, we feelthat his comments about device factors,     

Acute urinary retention: what is the impact on patients’ quality of life?

OBJECTIVE: To evaluate the impact of admission for acute urinary retention (AUR) on patients' health-related quality of life (HRQoL) compared with that on admission for elective surgery for benign prostatic hyperplasia (BPH) and emergency admission for renal colic (RC). PATIENTS AND METHODS: Over a 2-year period, three groups of men were recruited from one institution: group 1, men aged >50 years presenting to the accident and emergency (A&E) department with AUR; group 2, for comparison, men aged >50 years admitted for elective surgery for BPH; and group 3, men aged >40 years presenting to A&E with RC. A self-completed HRQoL questionnaire was administered at five visits (72 h from admission, and 1, 2, 3 and 6 months afterward) over a 6-month follow-up. RESULTS: Group 1 reported mean pain scores on admission of 7.7, compared with 5.6 for group 2 and 8.3 for group 3. Patients in group 1 had the most investigations and recurrent attendance to A&E throughout the study, compared with almost none for the other two groups. There was a substantial economic burden for group 1; 15% had extra help at home at a mean cost of 403 UK pounds for the duration of the study. For the other domains assessed (e.g. emotions, mental state, general health) groups 1 and 2 were similar. CONCLUSIONS: An episode of AUR has a measurable impact on patients' HRQoL, which often occurs in the community and therefore may not be appreciated by the urology team providing their care. Further work is therefore required to improve the "patient journey" for those with AUR, and to prevent patients developing AUR in the future.     

"Invalidity" due to chronic bronchitis and emphysema: how real is it?

Hospital discharges and deaths attributed to chronic bronchitis and emphysema have fallen in recent years while the number of those receiving invalidity benefit for these conditions has remained constant. One hundred and fifty seven such persons were invited to take part in this study, in which the diagnosis, degree of respiratory impairment, and other factors contributing to disability were reviewed. The scope for rehabilitation was considered. One hundred subjects agreed to take part; 96 were men and 70 were over 60 years. In only 67 was the main diagnosis chronic bronchitis and emphysema. There was a bimodal distribution of functional impairment, most being severely disabled, but in 20 the FEV1 was within the normal range. Among these asthma was more common and psychological factors were important. Economic factors contributed to "invalidity," especially among those with a normal FEV1. For 32 of the 57 who had declined to take part some information was available from hospital records. The findings in this group were similar. There was little scope for rehabilitation in the group as a whole as motivation was poor. Less than half had ever seen a chest physician. Specialist assessment before invalidity benefit is claimed is probably desirable.     

Who is responsible for operating room management and how do we measure how well we do it?

BACKGROUND: Managing the surgical process in the operating suite - often the most expensive unit in the hospital - is vital, yet challenging. While sensible management can improve efficiency, unclear managerial structures can hinder the optimal use of resources. Despite that, no previous data exists as to how the operating room management is organized and the performance monitored in our country. METHODS: A survey was sent to chief anesthesiologists and head nurses of 103 surgery units of 60 public hospitals regarding the current structures of daily management, as well as metrics and tools used for monitoring the performance of the operating room. RESULTS: The overall response rate was 87%. Nurses' and anesthesiologists' perceptions differed significantly on which care provider they held responsible for the daily operative management of the operating room. In doctors' opinion, that person was an anesthesiologist - either alone or in combinations - more often than in nurses' opinion (66% vs. 35%, P < 0.001). Anesthesiologists' involvement increased by the type and size of the hospital, being greatest in the university hospitals. Operating room performance was measured most often by number of procedures in a time unit, utilization and turnover time. Monitoring was complicated by old-fashioned information systems, and seldom seemed to lead to organizational changes. CONCLUSION: The structure of the daily operative management of an operating room needs redefining. There should be more focus on collaboration and communication between the care providers.     

Tolerance: is it worth the risk?

BACKGROUND: The success of orthotopic liver transplantation (OLT) has been limited by the adverse effects of immunosuppression. The purpose of this study was to determine the safety and feasibility of withdrawing immunosuppression in OLT recipients to achieve tolerance. METHODS: Eighteen adult OLT recipients in our steroid-free protocol without rejection were selected for this protocol. All patients chosen for this trial were on tacrolimus monotherapy with normal liver function tests (LFTs). Tacrolimus was weaned as long as LFTs remained stable. Weaning was halted for elevations of liver enzymes and tacrolimus was increased to the last dosage at which the patients had normal LFTs. Rejection was treated by increasing tacrolimus to levels of 10-15 ng/ml. Mycophenolate mofetil (MMF) or sirolimus was added if there was severe rejection by biopsy. Steroids were used if there was no improvement. RESULTS: One patient has been weaned off immunosuppression. Three additional patients were weaned completely off but had tacrolimus resumed because of mild elevations in LFTs. Eleven of 18 (61%) patients had rejection. Two patients required steroid therapy and one required rabbit antithymocyte globulin in addition to MMF and steroids. One of the patients with rejection developed diabetes and one patient had renal failure, which subsequently resolved. One patient died following a stroke. CONCLUSIONS: Clinical tolerance can be achieved in a minority of patients, even when being maintained on minimum immunosuppression. The potential benefit of achieving tolerance must be weighed against the risks of rejection therapy in patients doing well on low-dose immunosuppression.     

When does obstetric coagulopathy occur and how do I manage it?

Anticipating obstetric coagulopathy is important when obstetric anaesthetists are involved in the clinical management of women with postpartum haemorrhage. Although the incidence of coagulopathy in women with postpartum haemorrhage is low, significant hypofibrinogenaemia is associated with major haemorrhage-related morbidity and thus early identification and treatment is essential to improve outcomes. Point-of-care viscoelastic haemostatic assays, including thromboelastography and rotational thromboelastometry, provide granular information about alterations in clot formation and hypofibrinogenaemia, allow near-patient interpretation of coagulopathy, and can guide goal-directed treatment. If these assays are not available, anaesthetists should closely monitor the maternal coagulation profile with standard laboratory testing during the active phase of postpartum bleeding in order to rule coagulopathy ‘in or out’, decide if pro-haemostatic therapies are indicated, and assess the response to haemostatic support.     

Erection- and ejaculation-preserving cystectomy with orthotopic urinary diversion: is it feasible?

Nerve-sparing techniques to preserve sexual function in men undergoing cystoprostatectomy have been documented by different centers. We evaluated the results of the first 4 erection- and ejaculation-preserving cystectomies performed in our department. The ages of patients ranged between 36 and 43 years. In all cases, patients wished to maintain sexual function. Of the cases, 3 patients had pT1 G3 transitional cell carcinoma (TCC) refractory to treatment and one had pT2a adenocarcinoma of the bladder. Extirpation of the bladder and anterior proximal prostate en bloc with preservation of the vasa deferentia, seminal vesicles, posterior prostate, and neurovascular bundles was performed after pelvic lymphadenectomy. W-ileal neobladder was performed by using 40 cm of ileum. All patients had erections at the third month. Of the cases, 2 patients had antegrade ejaculation. The ejaculate volumes were 0.8 and 1.2 mL in patients with antegrade ejaculation. Patients in the other cases had retrograde ejaculation. All patients were continent day and night. We started clean intermittent catheterization in 1 case because of residual urine. There were no local recurrences. One patient with TCC died because of systemic disease in the postoperative 32nd month. The most important drawback of potent cases in cystectomy decision is erectile dysfunction after radical cystectomy. This drawback causes delay of the operation and sometimes mortality. As was the case in other reports, our limited number of cases in this study demonstrated that erection and ejaculation could be preserved in selected groups of patients.     

Urinary retention in female OAB after intravesical Botox injection: who is really at risk?

Introduction and hypothesis

Intravesical onabotulinumtoxinA (Botox) injections are effective for the treatment of idiopathic overactive bladder (OAB) symptoms. The aim of our study was to assess the predisposing factors for urinary retention in women with OAB after intravesical Botox injection.

Methods

All participants were women of European descent with idiopathic OAB. OnabotulinumtoxinA (100 U) was administered in 20 intra-detrusor injections. Analysis was performed based on the results of safety assessments made during follow-up (FU) visits on weeks 2, 4 and 12, in 208 women who were treated with Botox injections for refractory OAB and who completed all FU visits.

Results

Women who required clean intermittent self-catheterisation (CISC) and those with post-void residual (PVR) greater than 200 ml were older in comparison with patients with PVR between 50 and 200 ml. Patients who required CISC were also characterised by higher parity and particularly by a higher number of vaginal deliveries. Other factors such as body mass index or comorbidities did not significantly influence PVR and the risk of CISC.

Conclusions

Elderly and/or multiparous women are at increased risk of urinary retention after intravesical 100-U Botox injections. The risk of new onset urine retention in our study has completely disappeared 2 weeks after Botox injections. Based on our results of the way in which the PVRs have changed over time, we can conclude that OAB patients should be optimally assessed during the first 2 weeks after Botox injections.