Continuous spinal anesthesia and postoperative analgesia for elective cesarean section in a parturient with Eisenmenger’s syndrome

We describe the use of continuous spinal anesthesia (CSA) for an elective cesarean section in a 29-year-old parturient with Eisenmengers syndrome at 30 weeks of gestation. It is essential in patients with Eisenmengers syndrome to prevent significant increases in right-to-left shunt following the reduction in systemic vascular resistance. In this case, the patient hoped to be awake during the operation because of her fear of death. We therefore applied CSA to this patient because single-shot spinal anesthesia and epidural anesthesia might cause sudden cardiovascular depression. In fact, sudden cardiovascular changes were avoided by the titration of local anesthetics and the operation was uneventful, although prompt treatment of hypotension was essential and adjustment of the anesthetic levels was difficult. Postoperative patient-controlled spinal analgesia provided satisfactory pain relief with hemodynamic stability and no significant side effects. However, thorough experience with the requisite techniques is critical in CSA because of the technical difficulty of the procedure, and anesthesiologists must gain such experience in less-demanding cases before attempting to administer it in patients presenting extreme challenges as described in this case report.     

Neuraxial opioids for post-cesarean delivery analgesia: can hydromorphone replace morphine? A retrospective study

BackgroundCesarean delivery is the most common surgical procedure performed in the USA. We evaluated the postoperative analgesic properties of neuraxial hydromorphone compared to neuraxial morphine for post-cesarean delivery analgesia.MethodsA retrospective chart review was performed of women who underwent cesarean delivery and received neuraxial anesthesia from March to November 2011 and from March to November 2012. A total of 450 patients received intrathecal morphine 200 μg and 387 patients received intrathecal hydromorphone 60 μg. Eighty-one patients received epidural morphine 3 mg and 102 patients received epidural hydromorphone 0.6 mg.ResultsMedian time to first opioid after intrathecal morphine was 17.0 h versus 14.6 h after intrathecal hydromorphone (P <0.0001). Patients who received intrathecal hydromorphone consumed more opioids in the first 24 h; 37.0 mg versus 26.4 mg oral morphine equivalents (P <0.001). The side effect profile between the intrathecal groups was similar. Median time to first opioid with epidural morphine was 20.1 h versus 13.0 h with epidural hydromorphone (P=0.0007). Total opioid consumption was not significantly different between the epidural groups. The side effect profiles were similar.ConclusionsHydromorphone is a reasonable alternative to morphine for post-cesarean delivery analgesia. With the dosing used in our study, analgesia from morphine lasted longer than hydromorphone via intrathecal and epidural routes; however, neuraxial hydromorphone remains a reasonable option for long-acting analgesia post cesarean delivery.     

Commercial renal transplantation: A risky venture? A single Canadian centre experience

Background:

Canada, akin to other developed nations, faces the growing challenges of end-stage renal disease (ESRD). Even with expanded donor criteria for renal transplantation (the treatment of choice for ESRD), the supply of kidneys is outpaced by the escalating demand. Remuneration for kidney donation is proscribed in Canada. Without an option of living-related transplantation (biological or emotional donors), patients often struggle with long waiting lists for deceased donor transplantation. Accordingly, many patients are now opting for more expedient avenues to obtaining a renal transplant. Through commercial organ retrieval programs, from living and deceased donors, patients are travelling outside Canada to have the procedure performed.

Methods:

Between September 2001 and July 2007, 10 patients (7 males, 3 females) underwent commercial renal transplantation outside Canada. We describe the clinical outcomes of these patients managed postoperatively at our single Canadian transplant centre.

Results:

Six living unrelated and 4 deceased donor renal transplantations were performed on these 10 patients (mean age 49.5 years). All procedures were performed in developing countries and the postoperative complications were subsequently treated at our centre. The mean post-transplant serum creatinine was 142 μmol/L. The average follow-up time was 29.8 months (range: 3 to 73 months). One patient required a transplant nephrectomy secondary to fungemia and subsequently died. One patient had a failed transplant and has currently resumed hemodialysis. Acute rejection was seen in 5 patients with 3 of these patients requiring re-initiation of hemodialysis. Only 1 patient had an uncomplicated course after surgery.

Discussion:

Despite the kidney trade being a milieu of corruption and commercialization, and the high risk of unconventional complications, patients returning to Canada after commercial renal transplantation are the new reality. Patients are often arriving without any documentation; therefore, timely, goal-directed therapy for surgical and infectious complications is frequently delayed because of the time taken to establish an accurate diagnosis. Refuting the existence of commercial renal transplantation may not be a practical solution; more consistent communication and documentation with transplant teams may be more pragmatic. In the current climate, patients considering the option of overseas commercial renal transplantation should be advised of the potential increased risks.     

The TTK chitra heart valve—A single centre experience with midterm results

Background The Chitra TTK heart valve has been in use at G.K.N.M. Hospital, Coimbatore, as the valve of choice. Initially this valve was used as part of a multi-centric trial and later it was the valve of choice in our institution. Methods Between December 1992 and July 1998, a total of 152 Chitra valves were implanted and these form the basis of this study. There were 65 aortic and 64 mitral implants and the rest were double valves. Results There was one early death due to infective endocarditis. There were 7 late deaths, 3 in aortic group (mean interval after surgery being 18.6 months), 3 in mitral group (interval of 8.6 months) and 1 in double valve group (interval of 7 months). The cause of the late deaths included endocarditis in 2 patients and choked valve in 2 patients. In the rest, the cause of death could not be ascertained. The remaining 144 patients were followed up (a total of 622 patient years of follow-up) with clinical and echocardiographic evaluation. There were 11 patients (7.2%) with thrombo-embolic episodes, 5 of whom had major events and the rest were minor with a linearized rate of 1.8 percent patient year. Haemodynamic studies in postoperative patients were comparable to other prosthetic valves. The thrombo-embolism free survival was 82% at 5 years. The actuarial survival was 78% at 5 years. Conclusion The Chitra valve is comparable to other mechanical valves     

Do spinal cord injury patients always get the best treatment for neuropathic bladder after discharge from regional spinal injuries centre?

OBJECTIVE: To draw attention to inadequate care received by some spinal cord injury patients after discharge from the regional spinal injury center. SETTING: Regional Spinal Injuries Centre, Southport, UK. METHODS: Presence of the urethral stricture was not recognised in a 69-year-old male with T-3 paraplegia, who attended a health-care facility with a urinary infection. A Foley catheter was inserted into the urethra only half-way and the catheter balloon was then inflated in the urethra distal to the stricture. In a 68-year-old male with T-8 paraplegia, a long-term indwelling catheter was eroding the urethra and he developed a severe degree of hypospadias while being managed in the community. A 49-year-old male with C-4 tetraplegia developed recurrent urine infections. He received several courses of antibiotics, which were prescribed by community health professionals. But he continued to be unwell. Subsequently, the patient was admitted to a district general hospital, where he was diagnosed to have mild chest infection and was about to be sent home. However, his wife was not happy, and then ultrasound of abdomen was taken, which revealed pyonephrosis. He was then transferred to a spinal unit. RESULTS:: These patients were not seen promptly in a regional spinal injury centre when they developed medical problems. The complications, which ensued, might have been prevented if expert medical treatment had been provided without delay. CONCLUSION: In order to meet the needs of a growing population of persons living in the community with spinal cord injury, more beds are required in spinal units. Provision of day surgery wards within spinal units, out-reach clinics and home visits by spinal cord clinicians may reduce the demand for admission in a spinal unit. Education of community health professionals on delayed complications of spinal cord injury, and good communication between spinal cord clinicians, patients, carers, and community health professionals by telephone, e-mail or conventional postal system are likely to improve the care of spinal cord injury patients after discharge from spinal injury centres. Spinal cord clinicians should adopt a patient-centred care instead of the traditional, paternalistic, doctor-centred care.     

Epidural analgesia for blunt thoracic injury—Which patients benefit most?

IntroductionEpidural analgesia for blunt thoracic injury has been demonstrated to be beneficial for pulmonary function, analgesia, and subjective pain; however the optimal patient selection and timing of thoracic epidural placement have not been well studied. We hypothesised that early (<48 h) epidural analgesia (EA) as compared with usual care involving oral and intravenous narcotics delivered by patient-controlled analgesia (PCA) in patients with blunt thoracic trauma (>3 ribs fractured) is associated with fewer pulmonary complications and lower resource utilisation as measured by ICU and hospital length of stay.MethodsThis is a retrospective review of all non-intubated patients suffering from blunt thoracic injury with 3 or more rib fractures requiring hospital admission for >24 h over a recent 5-year period. Pulmonary complications were defined as pneumonia, empyema, hypoxia, and need for delayed intubation. Logistic regression was utilised to analyse patient and injury characteristics associated with pulmonary complications.Results187 patients were included in the analysis; early thoracic epidural was utilised in 18% (n = 34). There was no difference in age, ISS, ICU length of stay (LOS), or pulmonary complications between patients who received an epidural (EPI) compared with those who did not (NO EPI). A significantly increased incidence of pulmonary complications was noted in patients who required tube thoracostomy (p = 0.017).ConclusionIn our experience, insertion of a thoracic epidural catheter early post-injury failed to reduce the incidence of pulmonary complications, ICU and hospital LOS. However, since pulmonary complications are more frequent in patients requiring tube thoracostomy, the cost-effectiveness of epidural analgesia in these patients warrants further investigation.     

Clinical presentations and outcome analysis of renal transplant in elderly patients——A single center retrospective study

Objective To analyze the characteristics and prognosis of elderly renal transplant recipients. Methods The authors included 130 recipients older than or equal to 60 years at the time of operation in elderly group, and the paired 130 patients receiving contralateral renal transplants from the same donors and younger than 60 years in control group. All the patients received renal transplant in Kidney Disease Center of the First Affiliated Hospital of Zhejiang University from Nov 1994 to Dec 2013. Results The average age of the patients of elderly group was (63±3) years old, whereas the patients in control group were (41±10) years old. There was no significant difference in sex, type of dialysis, number of mismatched HLA, level of panel reactive antibodies (PRA), percentage of receiving induction therapy or immunosuppressive regimen between elderly group and control group, except that the patients in old group had a longer duration of dialysis. The patients of elderly group had a lower level of serum creatinine than control at the follow up times from 6 months to 24 months after transplant. The doses of immunosuppressives were lower in elderly group compared with the control group whereas the concentration of tacrolimus or cyclosporine was same. The dose of prednisone in old group was lower compared with control after 6 months post - transplantation. The patients of elderly group had high percentages of pulmonary infection and new-onset diabetes mellitus compared with the control group. Until June 2014, the follow-up rate of all patients was 85.4%; the median follow-up time was 70.4 months in elderly group and 79.9 months in control group. There was no significant differencein mortality rate or graft loss rate between elderly group and control group. Pulmonary infection (HR=2.981, P=0.018), hepatitis C virus infection (HR=5.797, P=0.003) and malignancies (HR=5.228, P=0.005) were correlated with the survival rate of the elderly group. Conclusions Elderly renal transplant recipients have a similar prognosis compared with the younger ones. Pulmonary infection, hepatitis C virus infection and malignancy are related risk factors for the survival rate of elderly patients.     

How many screws are necessary for subtalar fusion? A retrospective study

BackgroundBiomechanical studies have shown a higher compressive force and higher torsional stiffness for fixation with three screws compared to two screws. However, clinical data to compare these fixation techniques is still lacking.MethodsA retrospective analysis of 113 patients was performed, who underwent isolated subtalar fusion between January 2006 and April 2018.ResultsRevision arthrodesis was required in 8% (n = 6/36) for 3-screw-fixation and 38% (n = 35/77) for 2-screw-fixation. For 3-screw-fixation, non-union, was observed in 14% (n = 5/36) compared to 35% (n = 27/77) in 2-screw fixation. Non-union (p = .025) and revision arthrodesis (p = .034) were significantly more frequent in patients with 2 screws. A body mass index ≥30 kg/m² (p = .04, OR = 2.6,95%CI:1.1–6.3), prior ankle-fusion (p = .017,OR = 4.4,95%CI:1.3–14.5) and diabetes mellitus (p = .04,OR = 4.9,95%CI:1.1–17.8) were associated with a higher rate of revision arthrodesis.ConclusionsOur findings suggest that successful subtalar fusion is more reliably achieved with use of three screws. However, future prospective studies will be necessary to further specify this recommendation.     

Does postoperative locally applied second shot analgesia improve the patients' pain perception after tension free hernia repair? A doubleblinded study

Summary The aim of this study was to evaluate a possible advantage concerning the perceived level of pain following tension free hernia repair, by applying local anesthesia postoperatively. A prospective randomised double blind study was performed on patients undergoing tension free hernia repair according to the techniques of Lichtenstein. Two groups, each consisting of 30 patients, underwent tension free hernia repair under local anesthesia, during which a drainage tube was placed beneath the aponeurotic layer of the external oblique muscle. On the first postoperative day the patients received either local anesthesia (LA) or isotonic saline, through the drainage tube, which was then removed. For a period of six days, from the operation day onwards, the perceived level of pain was measured using a Visual Analogue Scale (VAS). All patients were mobilised early, the latest being 4 hours after the operation. Comparing the perceived pain levels (VAS) between the two groups of patients there was no significant or relevant advantages of applying local anesthesia. If performing the tension free hernia repair under local anesthesia conditions, the application of local anesthesia 24 hours later does not significantly reduce the perceived level of pain. This kind of analgesia is, therefore, not recommended for postoperative analgesia after tension free hernia repair.     

Who needs surgery for pediatric myelomeningocele? A retrospective study and literature review

Introduction

Children with myelomeningocele (MMC) are usually subjected to multiple surgeries. However, the number and type of surgeries are not the same in every patient with MMC over time. This report summarizes the surgical interventions in a cohort of several ages.

Materials and methods

Data on all of the patients with MMC, aged from 1 year and 10 months to 21 years and 11 months, were retrospectively reviewed at the Dona Estefânia Hospital in Lisbon, Portugal. Data were collected by chart review and individual interviews. The factors analyzed were demographics, ambulatory status, neurological level of involvement, shunt status, Arnold–Chiari malformation type II, surgical history, and occurrence of fracture. The surgical interventions were categorized as neurosurgical, orthopedic, urinary, ulcer repair and others.

Results

A total of 84 alive were eligible and enrolled. The average age was 14 years and six months. A total of 59 patients received shunts (all but one ventriculoperitoneal). In the study group, the 84 patients required 663 surgeries. Neurosurgical interventions were the most frequent surgical procedure and predominated during the first 2 years of life. Surgical interventions related to shunts were the most common neurosurgical interventions. Orthopedic surgeries were more frequent in the age group 6–12 years. Urological surgeries were done mainly after 6 years of age. Surgical repair of pressure ulcers was more common after 12 years of age.

Conclusions

Our study brings to light the complexity of this condition, with multiple surgeries among patients with MMC.     

A retrospective and consecutive analysis of the epidemiology and management of spinal cavernomas over the last 20 years in a single center

Spinal cavernous malformations (SCM) are rare lesions often presenting with acute onset of symptoms and progressive neurological deterioration due to hemorrhage into the spinal cord. With the aid of modern techniques, their surgical removal became much safer. The present study was undertaken to analyze the outcome of our series of surgically and conservatively treated patients with SCM. Over a period of 20 years, 20 surgically treated and 5 conservatively managed patients with spinal cavernous malformations were identified and enrolled into this analysis. Demographic data, clinical symptoms, localization and extension of the cavernoma, as well as pre- and postoperative neurological status were obtained. The clinical status was assessed using the Frankel score. Patients were followed up clinically and by MRI. Before surgery, 90 % (18/20) of our surgical patients were classified as Frankel D (93.8 %), whereas two patients (10 %) were graded C. None of the patients had a worse Frankel score at the time of discharge. Eighty percent of them (16 cases) remained unchanged, and 20 % (4 patients) improved during the first follow-up (mean 6.3 months, range 2–17 months). All improved patients had a superficially located SCM and were operated early (≤3 months). No worsening was observed during extended follow-up (range 9–134 months, mean 44.7 months). Five nonsurgically treated patients showed no significant clinical deterioration over a period of 6.7 years (mean, range 2.9–8 years). SCM localization and number of involved segments had no influence on outcome. Our data show that SCM can be resected with favorable neurological outcome by using intraoperative neuromonitoring. Within the follow-up period, patients treated conservatively remained in a stable neurological condition.