Can There be a Place for Intraoperative Salvaged Blood in Spine Tumor Surgery?

Background

Intraoperative cell salvage (IOCS) has been used in musculoskeletal surgery extensively. However, it has never found its place in musculoskeletal oncologic surgery. We have conducted the first-ever study to evaluate the feasibility of IOCS in combination with a leucocyte-depletion filter (LDF) in metastatic spine tumor surgery. This was to pave the path for use of IOCS-LDF in musculoskeletal oncologic surgery.

Methods

Patients with a known primary epithelial tumor, who were offered surgery for metastatic spinal disease, were recruited. Blood samples were collected at three different stages during the surgery: from the operative field before IOCS processing, after IOCS processing, and after IOCS-LDF processing. Three separate samples (5 mL each) were taken at each stage. Samples were examined using immunohistochemical monoclonal antibodies to identify tumor cells of epithelial origin.

Results

Of 30 patients in the study, 6 were excluded for not fulfilling the inclusion criteria, leaving 24 patients. Malignant tumor cells were detected in the samples from the operative field before IOCS processing in eight patients and in the samples from the transfusion bag after IOCS processing in three patients. No viable malignant cell was detectable in any of the blood samples after passage through both IOCS and LDF.

Conclusions

The findings support the notion that the IOCS-LDF combination works effectively in eliminating tumor cells from salvaged blood, so this technique can be applied successfully in spine tumor surgery. This concept can then further be extended to whole musculoskeletal tumor surgery and other oncologic surgeries with further appropriate clinical studies.     

Recovery Profile, Costs, and Patient Satisfaction with Propofol and Sevoflurane for Fast-track Office-based Anesthesia

Background: Office-based surgery is becoming increasingly popular because of its cost-saving potential. Both propofol and sevoflurane are commonly used in the ambulatory setting because of their favorable recovery profiles. This clinical investigation was designed to compare the clinical effects, recovery characteristics, and cost-effectiveness of propofol and sevoflurane when used alone or in combination for office-based anesthesia.

Methods: One hundred four outpatients undergoing superficial surgical procedures at an office-based surgical center were randomly assigned to one of three general anesthetic groups. In groups I and II, propofol 2 mg/kg was administered for induction followed by propofol 75-150 [micro sign]g [middle dot] kg-1 [middle dot] min-1 (group I) or sevoflurane 1-2% (group II) with N2 O 67% in oxygen for maintenance of anesthesia. In group III, anesthesia was induced and maintained with sevoflurane in combination with N (2) O 67% in oxygen. Local anesthetics were injected at the incision site before skin incision and during the surgical procedure. The recovery profiles, costs of drugs, and resources used, as well as patient satisfaction, were compared among the three treatment groups.

Results: Although early recovery variables (e.g., eye opening, response to commands, and sitting up) were similar in all three groups, the times to standing up and to be "home ready" were significantly prolonged when sevoflurane-N2 O was used for both induction and maintenance of anesthesia. The time to tolerating fluids, recovery room stay, and discharge times were significantly decreased when propofol was used for both induction and maintenance of anesthesia. Similarly, the incidence of postoperative nausea and vomiting and the need for rescue antiemetics were also significantly reduced after propofol anesthesia. Finally, the total costs and patient satisfaction were more favorable when propofol was used for induction and maintenance of office-based anesthesia.     

Dexmedetomidine: perioperative applications in children

Dexmedetomidine is a highly specific and selective alpha‐2‐adrenergic agonist with sedative, anxiolytic, and organ protective effects. Its clinical applications in children include premedication, prevention of emergence delirium, as part of multimodal anesthetic regimen and sedation in the pediatric intensive care unit. Its role in neuroprotection in children undergoing anesthesia should be explored. In this review, various uses of dexmedetomidine are discussed in detail.     

Energy‐Dense Formulae May Slow Gastric Emptying in the Critically Ill

Background: Enteral feed intolerance occurs frequently in critically ill patients and can be associated with adverse outcomes. “Energy‐dense formulae” (ie, >1 kcal/mL) are often prescribed to critically ill patients to reduce administered volume and are presumed to maintain or increase calorie delivery. The aim of this study was to compare gastric emptying of standard and energy‐dense formulae in critically ill patients. Methods: In a retrospective comparison of 2 studies, data were analyzed from 2 groups of patients that received a radiolabeled 100‐mL “meal” containing either standard calories (1 kcal/mL) or concentrated calories (energy‐dense formulae; 2 kcal/mL). Gastric emptying was measured using a scintigraphic technique. Radioisotope data were collected for 4 hours and gastric emptying quantified. Data are presented as mean ± SE or median [interquartile range] as appropriate. Results: Forty patients were studied (n = 18, energy‐dense formulae; n = 22, standard). Groups were well matched in terms of demographics. However, patients in the energy‐dense formula group were studied earlier in their intensive care unit admission (P = .02) and had a greater proportion requiring inotropes (P = .002). A similar amount of calories emptied out of the stomach per unit time (P = .57), but in patients receiving energy‐dense formulae, a greater volume of meal was retained in the stomach (P = .045), consistent with slower gastric emptying. Conclusions: In critically ill patients, the administration of the same volume of a concentrated enteral nutrition formula may not result in the delivery of more calories to the small intestine over time because gastric emptying is slowed.     

Hypotension during thoracic surgery under combined general and high thoracic epidural anesthesia

High thoracic epidural anesthesia (TEA) is increasingly often used in combination with general anesthesia for major thoracic and abdominal surgery. TEA leads to sympatholysis of cardiac efferences leading to improved myocardial oxygen balance, which is in part due to vasodilation of atherosclerotic coronary vessels. To provide the full benefit of TEA, it is important to extend it as patient-controlled epidural analgesia in the postoperative period. If adequate vascular volume is maintained, hypotension is less frequent after TEA than after lumbar epidural anesthesia. However, in combination with general anesthesia, it may be more frequent and more severe. Treatment of hypotension is sometimes difficult and may require the use of nonadrenergic vasoconstrictors (eg, vasopressin). Copyright © 2000 by W.B. Saunders Company     

Hip Resurfacing in an 88-Year-Old Patient? : Highlighting Selection Criteria for Hip Resurfacings in Patients Older than 65 Years

The success of hip resurfacings in the older population is still to be determined, although it has been an attractive option in the much younger patients with arthrosis of the hip. We present a 95-year-old active, independent patient who underwent a Birmingham hip resurfacing at 88 years of age. More than 7 years after surgery, the original components are still in situ, and the patient is pain-free with a very active lifestyle at the age of 95 years. Hip resurfacings are not without risks, and we highlight the evolution of strict selection criteria for patients older than 65 years who may be suitable candidates for hip resurfacing arthroplasty.     

An audit of transfusion of red blood cell units in pediatric anesthesia

Background:  Patients undergoing surgery are an important user of red blood cells (RBC). Increasingly, medical staff and patients wish to know the likelihood of RBC transfusion for appropriate resource allocation and to inform preoperative discussions regarding risk. Although some adult data are available, little is known about RBC use in children.
Aim:  The aim of this study was to describe RBC use in the perioperative period in a large pediatric hospital.
Methods:  Over a 2-year period the hospital operating theatre database and trauma registry was merged with the blood bank database to identify episodes where RBC units were transfused in association with anesthesia. Incidence of transfusion of RBC units associated with particular procedures was then calculated.
Results:  A total of 21 441 patients underwent 32 511 anesthetics from January 1, 2006 to December 31, 2007, and 9838 units of RBC were released from the hospital blood bank of which 4070 (41%) were transfused in the perioperative period. Cardiac surgery was the greatest user of RBC units (2359 units). Acute major trauma accounted for only 159 units. Overall 6.3% of anesthetics were associated with a RBC transfusion. The procedures with the greatest frequency of RBC transfusion were cardiac surgery on bypass (79%), cardiac off bypass (55%), liver transplant (87%) and cranioplasty (61%).
Conclusion:  In a tertiary pediatric hospital surgery accounts for a substantial proportion of total RBC use, with particular procedures accounting for the majority of transfusions.     

Ultrasound guided vascular access: efficacy and safety

In the United Kingdom and United States, US guidance for internal jugular central venous catheterisation is recommended. Despite reluctance to adopt these guidelines, there is sufficient evidence to support routine use, as even proceduralists skilled in landmark techniques commonly encounter complications. Serious morbidity and mortality may result, which arguably is avoidable, if ultrasonography was used. Real-time 2D US demonstrates patient anatomy and anatomical variability in a manner not previously possible for anaesthetists. Unencumbered by reliance on surface landmarks, the needle path and tip can be visually directed into the target vessel lumen. This potent ability improves successful cannulation and first-attempt success, reduces the number of needle attempts and decreases mechanical complications associated with vascular access procedures.

Conflict of interest

AC has received honoraria from SonoSite and AstraZeneca as a workshop tutor for teaching ultrasound-guided procedures.