Scoliosis surgery in children

The first 150 words of the full text of this article appear below. Key points Scoliosis is most commonly idiopathic in origin,but it may be congenital or secondary to neuromuscular disease,trauma, infection or neoplasm. Surgery aims to correct thecurvature, improve posture and reduce progression of respiratorydysfunction. Cardio-respiratory dysfunction may exist as aresult of progressive scoliosis or be related to coexistingdisease, therefore careful preoperative assessment is required. Intraoperativeconsiderations include the prone position, avoiding hypothermia,minimizing blood loss and monitoring spinal cord function. Goodpostoperative pain control is essential and requires a multimodalapproach.   Scoliosis is a lateral curvature and rotation of the thoraco-lumbarvertebrae with a resulting rib cage deformity. It may be idiopathicor secondary to neuromuscular disease, infection, tumour orinjury (Table 1). View this table: [in this window] [in a new window]   Table 1 Classification of scoliosis aetiology   Curvature is measured using the Cobb angle (Fig. 1). A lateralcurve of >10° is considered abnormal.¹      

Nosocomial infections

Nosocomial infections can be defined as those occurring within48 hours of hospital admission, 3 days of discharge or 30 daysof an operation. They affect 1 in 10 patients admitted to hospital.Annually, this results in 5000 deaths with a cost to the NationalHealth Service of a billion pounds. On average, a patient withhospital acquired infection spent 2.5-times longer in hospital,incurring additional costs of £3000 more than an uninfectedpatient. Intensive care units (ICU) have the highest prevalenceof hospital-acquired infections in the hospital setting. TheEuropean Prevalence of Infection in Intensive Care Study (EPIC),involving over 4500 patients, demonstrated that the nosocomialinfection prevalence rate in ICU was 20.6%.¹ ICU patients areparticularly at risk from nosocomial infections as a resultof mechanical ventilation, use of invasive procedures and theirimmunocompromised status (Table 1). View this table: [in this window] [in a new window]   Table 1 Factors that predispose to nosocomial infections.       

A (pain free) step in the right direction

Anaesthetics is a broad field. Anaesthetists have provided thebasis for many advances in surgical techniques and improvementin outcomes, while allowing ever more traditionally unfit patientsto be treated. Not satisfied with that, we expand ever moreinto the field of surgical pathology, co-developing minimallyinvasive alternative treatments. There are many examples inthe field of chronic spinal pain (Table 1). View this table: [in this window] [in a new window]   Table 1 Pain generating anatomical spinal structure,^16–18 with the possible surgical and minimally invasive treatment   Igarashi and colleagues, in this issue,¹ do not claim     

Anaesthesia and critical care of Jehovah's Witnesses

The Jehovah's Witness religion is a Christian movement, foundedin the US in the 1870s, with 6 million members worldwide (150,000in the UK). Members of this faith have strong beliefs basedupon passages from the Bible that are interpreted as prohibitingthe ‘consumption’ of blood. Their beliefs preventthem from accepting transfusion of whole blood or its primarycomponents. They also believe that blood that has been removedfrom the body is ‘unclean’ and should be disposedof. The use of procedures that involve the removal and storageof their own blood are often unacceptable (Table 1). View this table: [in this window] [in a new window]   Table 1 Acceptability of blood products and transfusion-related procedures in Jehovah's Witnesses   Blood-free major surgery in the Jehovah's Witness patient presentsa challenge to the anaesthetic and surgical team. The problemsassociated with their management highlights a growing health-careissue – the supply, safety and appropriate use of bloodproducts. Techniques learnt from treating them may prove beneficialto all patients undergoing major surgery.     

Endocrine and metabolic response to surgery

The neuroendocrine, metabolic and inflammatory aspects of injuryare part of the overall ‘stress response’ (Table 1).This has been studied most commonly in relation to surgery,because the catabolic changes that occur can be observed froma well-defined starting point, but similar features occur intrauma, burns, severe infection and strenuous exercise. Theseresult in substrate mobilization, muscle protein loss and sodiumand water retention, with suppression of anabolic hormone secretion.There is activation of the sympathetic nervous system and immunologicaland haematological changes. Generally, the magnitude of themetabolic response is proportional to the severity of the surgicaltrauma. These changes have probably evolved to aid survivalin a more primitive environment, by mobilizing substrates, limitingtissue damage, destroying infectious organisms and activatingrepair processes. Psychological and behavioural changes accompanythe physiological events. The benefits of the stress responseare not obvious in modern medicine, when physiological changescan be more easily corrected and it may even have a detrimentaleffect. In recent years, research has focused on methods tomodify the response associated with surgery in an attempt toimprove patient outcome. View this table: [in this window] [in a new window]   Table 1 Changes occurring during the stress response       

Atracurium associated with postoperative residual curarization

Editor—We were interested to read the short communicationregarding residual neuromuscular block after atracurium administrationby McCaul and colleagues.¹ We have recently conducted a similarsurvey in our hospital, based on the work by Hayes and colleagues.²We measured the train-of-four ratio (TOFR) in adult patientsin our recovery ward using a Datex Ohmeda Accelerometer. Theproject was performed without the knowledge of the patients’anaesthetist, in an attempt to avoid a change in their usualclinical practice. We recorded type and dose of neuromuscularblocking agent, the timing and doses of increments, whetherantagonism was given, and whether a peripheral nerve stimulator(PNS) was used (Table 1). View this table: [in this window] [in a new window]   Table 1 Patient characteristics. Values are absolute (n) or     

The CobraPLA in 110 anaesthetized and paralysed patients: what size to choose?

Editor—The Cobra Perilaryngeal Airway (PLA)^TM is a newsupraglottic device,¹ which consists of a tube with an inflatablecuff and a 15 mm standard adaptor. The softened distal end (CobraPLA^TMhead) of the breathing channel is designed to be positionedin the hypopharynx, opposite the laryngeal inlet, to divertthe inspiratory gas into the trachea through the slotted openings(Fig. 1). View larger version (75K): [in this window] [in a new window]   Fig 1 The CobraPLA^TM.   Ethics committee approval and written informed consent was obtainedfrom the patients before     

Pharmacotherapy of neuropathic pain

The first 150 words of the full text of this article appear below. Key points The pathophysiology of neuropathic pain is complex. Treatmentof neuropathic pain is often poorly understood by healthcareprofessionals and consequently not managed well. The mainstayof therapy is tricyclic anti-depressants and anti-epilepticdrugs. Strong opioids have a role in some patients.