Capillary refill time: is it still a useful clinical sign?

Capillary refill time (CRT) is widely used by health care workers as part of the rapid, structured cardiopulmonary assessment of critically ill patients. Measurement involves the visual inspection of blood returning to distal capillaries after they have been emptied by pressure. It is hypothesized that CRT is a simple measure of alterations in peripheral perfusion. Evidence for the use of CRT in anesthesia is lacking and further research is required, but understanding may be gained from evidence in other fields. In this report, we examine this evidence and factors affecting CRT measurement. Novel approaches to the assessment of CRT are under investigation. In the future, CRT measurement may be achieved using new technologies such as digital videography or modified oxygen saturation probes; these new methods would remove the limitations associated with clinical CRT measurement and may even be able to provide an automated CRT measurement.     

Tip variant of focal segmental glomerulosclerosis: is it truly a benign variant?

Abstract

Background: Even though frequently described as a benign entity, the outcomes of the tip variant of focal segmental glomerulosclerosis (FSGS) have proven to be unclear. Methods: This retrospective study includes a cohort of tip variant cases who presented to us from 2009 to 2012 and the analysis of their presenting clinical, histopathological features and treatment outcomes in comparison to the not otherwise specified (NOS) variants from our center in East India. Results: Of the 224 biopsies of primary FSGS, 30 cases were the tip variant (13.39%). The mean age of presentation was around 29 years, with 57% being males. A nephrotic presentation was seen in 87% of cases, with 20% showing a presentation at <18 years of age for the first time. Global sclerosis, interstitial fibrosis, tubular atrophy and arteriolar hyalinosis were seen more commonly in the NOS variant. Twenty five patients of tip variant received steroid therapy and eight received alternative immunosuppression. Around 87% of the tip variant cases achieved some form of remission in proteinuria and 13.3% had a doubling of creatinine at a median follow-up of 2 years in comparison to NOS group in which 80% achieved some form of remission and 20% had a doubling of creatinine. Conclusion: Though the histopathological features and treatment responsiveness of the tip variant appear to be better than the NOS variety, the prognostic outcome does not seem to be as favorable as implicated previously with an important percentage of patients showing progressive worsening of renal function within a relatively short time span (2 years) in our cohort.     

Periappendicitis: is it a clinical entity?

The aim of this study was to identify clinical parameters that may help distinguish periappendicitis from the more common clinical entity of acute appendicitis. Serosal inflammation of the appendix without mucosal involvement constitutes the condition known as periappendicitis. In most situations this is a sequel of extra-appendicular sepsis and is likely to benefit from treatment targeted to the underlying pathology. But the majority of these cases are initially treated for acute appendicitis as clinical distinction between the two conditions is difficult. In this study some commonly used clinical yardsticks have been analyzed with respect to their value in this subtle diagnosis. We reviewed 231 successive cases clinically diagnosed as acute appendicitis; of these 18 had histologically demonstrated periappendicitis. Eight parameters were studied: age, gender, temperature, white blood cell count, location and duration of pain, associated symptoms, and peritoneal signs. Significant statistical differences were found between the two groups with regard to pain location, pain duration, and the presence of peritoneal signs. It may be possible to suspect periappendicitis preoperatively with meticulous clinical assessment. This may be of value in avoiding missed nonappendicular pathologies.     

Hepatic portal venous gas: is it always a sign of severity and surgical emergency?

Hepatic portal venous gas is a radiological finding due to the presence of gas in the portal vein. It was associated with a mortality rate ranging from 75% to 90% and with an indication for exploratory laparotomy. We report one case following an abdominal trauma. The portal vein gas was detected on CT Scan. The patient who was asymptomatic was not operated on and survived. The severity of this radiological symptom requiring a laparotomy has to be reassessed. CT Scan is the most efficient method to recognize portal vein gas and its larger use has allowed to diagnose more cases not detected by simple abdominal X-rays. In conclusion, surgical exploration should not be done systematically but has to be decided in relation with the clinical status of the patient.     

Heart displacement during off-pump CABG: how well is it tolerated?

BACKGROUND: Heart displacement during off-pump coronary artery bypass grafting (CABG) is necessary to expose the anastomosic sites. We analyzed the hemodynamic changes in relation to the grafted arteries. METHODS: The relationship between surgical exposure and hemodynamic management was assessed in 150 consecutive patients undergoing off-pump CABG utilizing the Octopus Tissue Stabilization System (Medtronic, Minneapolis, MN). RESULTS: Surgical exposure by anterolateral thoracotomy showed no significant hemodynamic changes. Through sternotomy, stroke volume was significantly reduced by dislocation at all target sites: by 6% at the left anterior descending artery (LAD), 25% at the diagonal branch artery (D), 14% at the right coronary artery (RCA), and 21% at the obtuse marginal artery (OM). The application of head-down positioning (LAD, 56%; D, 74%; RCA, 90%; OM, 96%) increased not only surgical exposure but also preload, producing correction of ventricular filling pressures and output. In a minority of cases, dopamine (3 to 5 microg x kg(-1) x min(-1)) was added to maintain baseline hemodynamic values (LAD, 5%; D, 15%; RCA, 7%; OM, 28%). CONCLUSIONS: Revascularization during anterolateral thoracotomy was uneventful. The sternotomy approach with heart displacement induced right heart compression. Mainly fluid redistribution was sufficient to correct cardiac output. Once stabilized, systemic circulation remained unchanged during revascularization.     

Estimating the risk of pressure ulcer development: is it truly evidence based?

The aim of the current method of screening patients is to identify risk factors that are considered to cause, or contribute to, pressure ulcer (PU) development. Yet screening has not resulted in a reduction in pressure ulcer development. The literature was reviewed to identify the level of evidence for the inclusion of risk factors in six published pressure ulcer risk-screening tools. Evidence for each risk factor was ranked according to the National Health and Medical Research Council levels of evidence with a modification. Three of 19 risk factors (mobility, continence and nutrition) included in more than one screening tool have been tested for association with pressure ulcer development. While varying degrees of immobility and decreased serum albumin are reported to significantly increase the risk for PU development, the direction of the relationship, i.e. causal or resultant of PU, is not always clear. No publications reported a significant causal link between incontinence and PU development. Inclusion of risk factors for PU in screening tools must be evidence based. Until other risk factors have been tested for positive predictive value, the Ramstadius approach to screening is the only evidence-based tool.     

The esophageal coin: is it a penny?

Because of their high zinc content modern U.S. pennies that become lodged in the esophagus may react with stomach acid thereby damaging the esophageal mucosa. Management of esophageal pennies may therefore differ from that of other esophageal coins making differentiation of pennies from other coins important. We reviewed the records of 111 children who underwent endoscopic esophageal coin removal over a 19-year period to determine the ability of history and size of esophageal coin images on posterior-anterior and lateral chest radiographs alone and in combination to differentiate esophageal pennies from other esophageal coins. History alone accurately identified 83 per cent of esophageal coins. Ranges of two standard deviations around mean image sizes were determined for each coin denominations. We determined the probability of an esophageal coin being a penny based on combinations of historical data and whether or not image sizes fell within the calculated range for a penny. When all data agree that a coin is or is not a penny they are nearly always correct. When there is disagreement among historical and image size data the probability that is a coin is a penny is strongly influenced by the size of the radiographic images.     

Splenic vein aneurysm: is it a surgical indication?

Splenic vein aneurysms are rare and are usually caused by portal hypertension. Symptoms are unusual, but may include rupture or abdominal pain. Diagnosis can usually be made either by means of duplex ultrasonography or computed tomography scanning. Treatment varies from noninvasive follow-up to aneurysm excision. We report an expanding splenic vein aneurysm in a young woman with abdominal and back pain and no history of portal hypertension. She was treated with aneurysm excision and splenectomy.     

Carotid-carotid crossover bypass: is it a durable procedure?

PURPOSE: Reconstruction of a diseased common carotid artery may necessitate direct repair via aortic artery-based revascularization. However, carotid-carotid artery crossover grafting is an alternative extra-anatomic option that obviates the need for median sternotomy. We analyzed our results with carotid-carotid artery crossover bypass surgery. METHODS: Data were analyzed for all patients undergoing carotid-carotid crossover bypass surgery from 1995 to 2000. Data on patient demographics, indications for surgery, perioperative morbidity and mortality, and graft patency were retrieved from a vascular surgery data base and hospital records. Stroke-free survival and graft patency were determined with life table methods. RESULTS: Over 5 years, 24 carotid-carotid artery crossover bypass procedures were performed to treat both symptomatic (n = 19, 79%) and asymptomatic (n = 5, 17%) disease. Nine procedures (38%) were performed in men, 3 (13%) in patients with diabetes, 12 (50%) in active smokers, and 2 in patients with a history of Takayasu arteritis. Patient mean age was 63 years (range, 38-79 years). Twenty-three patients (96%) received polytetrafluoroethylene conduit grafts, and the remaining patients received vein grafts. Ten (42%) patients underwent concomitant endarterectomy. There were no perioperative deaths. One patient (4%) had asymptomatic early occlusion, one had transient neurologic deficit (4%), one (4%) required additional surgery because of bleeding, and one (4%) had a perioperative cerebrovascular accident (stroke). Three (17%) asymptomatic late occlusions were identified at 11, 57, and 64 months, respectively. Mean follow-up was 30 months (range, 1-70 months). Primary patency was 88%, and secondary patency was 92% at 3 years. Stroke-free survival was 94% at 4 years. CONCLUSION: Carotid-carotid artery crossover bypass surgery is a safe and durable procedure. Its use precludes the need for median sternotomy and provides acceptable stroke-free survival.     

Anaesthetic organ toxicity: is it really a problem?

The hepatotoxicity of halothane is now well known, but only became apparent after several years of use. The nephrotoxicity of methoxyflurane was not realized immediately, but once identified, led to its withdrawal from use. Therefore, when new agents that appear to offer significant advantages over established drugs become available, exhaustive testing and monitoring is necessary to ensure their safety. Sevoflurane, recently available in the UK and the USA but used for some time in Japan, has been subjected to considerable scrutiny.