Sedation and anesthesia care for ophthalmologic surgery during local/regional anesthesia

Anesthesia care for the patients undergoing ophthalmologic surgical procedures during local/regional anesthesia balances goals of patient comfort with safety and an optimal outcome in a highly cost-conscious environment. This article discusses current practices and trends in anesthesia care with respect to sedation for eye surgery during local/regional anesthesia. Although there is no evidence that one local/regional anesthesia technique or sedation analgesia regimen is superior to the others, this review highlights important differences between these varied approaches. The type of block used for the ophthalmologic surgery alters the sedation requirements. Changes in surgical techniques have increased the popularity of topical anesthesia, which reduces the need for sedation analgesia and may lessen the need for an anesthesia practitioner. The involvement of an anesthesia practitioner in eye surgery varies from facility to facility based on costs, anesthesiologist availability, and local standards. Anesthesia care choices are often made based on surgeon skill and anesthesiologist comfort, as well as the expectations and needs of the patient.     

Unreamed interlocking nailing in open fractures of tibia

PURPOSE: To assess the clinical outcome of unreamed intramedullary interlocking nailing in open fractures of tibia, and to evaluate the incidence of complications in these open fractures as a result of the unreamed intramedullary nailing. METHODS: Between June 1999 and May 2000, a total of 60 cases of open tibial shaft fractures were operated on with unreamed interlocking nails at Safdarjung Hospital, New Delhi, India. Records of 56 patients (4 women and 52 men) were available for study. Only injuries associated with the tibial shaft were included. Traffic accidents were the cause of fractures in all patients. All fractures were classified according to Gustilo and Anderson system for open fractures. There were 30 (53.6%) type-I, 18 (32.1%) type-II, 4 (7.1%) type-IIIA, and 4 (7.1%) type-IIIB fractures. After thorough debridement under anaesthesia, an unreamed interlocking nail was inserted with assistance by an image intensifier. All nails were statically locked with one screw each proximally and distally. RESULTS: The patients were followed up for a mean period of 20 months (range, 18-24 months) and were evaluated according to the modified Ketenjian's criteria. Results were good to excellent in 85.8% cases, and poor in 10.7% cases. Only 2 of 8 patients with type-III fractures had good results. Two of 4 type-IIIA and all 4 type-IIIB fractures had chronic osteomyelitis. Of 56 patients, 6 had early infection, 6 had delayed union, 6 had infected non-union, 2 had nail breakage, 8 had screw breakage, and 10 had anterior knee pain. CONCLUSION: Unreamed interlocking tibial nailing can be safely used for type-I and type-II open injuries even with delayed presentation. Use of unreamed nailing in those type-III fractures with delayed presentation was not recommended, because of high incidence of complications.     

Rhabdomyolysis with acute kidney injury in deceased donors is not a contraindication for kidney donation

Purpose

Deceased patients with acute kidney injury (AKI) from rhabdomyolysis can be considered as potential kidney donors.

Methods

We performed a retrospective chart review from January 2005 to January 2011 of three donors with AKI from rhabdomyolysis and the four recipients of the donated kidneys. Three donors had AKI from rhabdomyolysis as evidenced by elevated serum creatinine levels, myoglobinuria, and plasma creatinine kinase levels greater than five times the upper limit of normal. All grafts were maintained on pulsatile machine perfusion (MP) prior to transplantation. In one of the patients, serial venous perfusate myoglobin levels were measured from the donor kidney while on MP.

Results

Three of the four recipients had delayed graft function, but all had normalized creatinine function after 1?month. One recipient had a creatinine of 1.2 after 79?months, the longest documented follow-up of this kind. Although we measured venous perfusate myoglobin levels from one of the grafts, we found the levels to decrease with increasing time spent on MP.

Conclusion

Potential donors with AKI secondary to rhabdomyolysis should not be restricted from the donor pool. MP may play a role in minimizing the effects of AKI in these types of donors.     

Endotracheal intubation in the field does not improve outcome in trauma patients who present without an acutely lethal traumatic brain injury

OBJECTIVES: There is an absence of prospective data evaluating the impact of prehospital intubation in adult trauma patients. Our objectives were to determine the outcome of trauma patients intubated in the field who did not have an acutely lethal traumatic brain injury (death within 48 hours) compared with patients who were intubated immediately on arrival to the hospital. METHODS: Prospective data were collected on 191 consecutive patients admitted to the trauma center with a field Glasgow Coma Scale score < or = 8 and a head Abbreviated Injury Scale score > or = 3 who were either intubated in the field or intubated immediately at admission to the hospital. Patients who died within 48 hours of admission and transfers were excluded from the study. RESULTS: Of the 191 patients, 176 (92%) sustained blunt trauma and 25 (8%) were victims of penetrating trauma. Seventy-eight (41%) of the 191 patients were intubated in the field and 113 (59%) were intubated immediately at admission. There was no significant difference in age, Glasgow Coma Scale score, head Abbreviated Injury Scale score, or Injury Severity Score between the two groups. Patients who were intubated in the field had a significantly higher morbidity (ventilator days, 14.7 vs. 10.4; hospital days, 20.2 vs. 16.7; and intensive care unit days, 15.2 vs. 11.7) compared with patients intubated on immediate arrival to the hospital and nearly double the mortality (23% vs. 12.4). Field-intubated patients had a 1.5 times greater risk of nosocomial pneumonia compared with hospital-intubated patients. CONCLUSION: Prehospital intubation is associated with a significant increase in morbidity and mortality in trauma patients with traumatic brain injury who are admitted to the hospital without an acutely lethal injury. A randomized, prospective study is warranted to confirm these results.     

Conversion of a fused hip to total hip arthroplasty

BACKGROUND: Arthrodesis of the hip remains a viable treatment for severe unilateral arthritis after traumatic injury or infection in a young but otherwise healthy individual. The goal of the present study was to review the long-term clinical and radiographic results after conversion of a fused hip to a total hip arthroplasty and to identify the risk factors that would lead to a higher rate of failure. METHODS: We performed a retrospective review of the charts and radiographs of 187 patients (208 hips) who had conversion of a fused hip to a total hip arthroplasty. The mean duration of follow-up after the conversion to total hip arthroplasty was 9.2 years (range, two to twenty-six years). RESULTS: The mean age at time of the arthroplasty was fifty-one years. The mean time-interval between the arthrodesis and the conversion to a total hip arthroplasty was twenty-seven years. According to the information in the charts, at a mean duration of follow-up of 9.2 years after the total hip arthroplasty, 79% of hips were either pain-free or had minimal pain, 83% had good-to-excellent function, and 79% had good-to-excellent range of motion. Complications, which included fifteen nerve palsies, occurred in twenty-four hips. Twenty-eight hips had heterotopic ossification, but it was not associated with a recurrence of ankylosis or a marked reduction of motion. Revision arthroplasty was performed in twelve hips. The probability of survival of the implant was 96.1% (95% confidence interval, 91.5% to 98.2%) at ten years, 89.9% (95% confidence interval, 85.3% to 96.1%) at fifteen years, and 72.8% (95% confidence interval, 36% to 90.6%) at twenty-six years. CONCLUSIONS: Conversion of a fused hip to a total hip arthroplasty has a favorable outcome. However, the technically demanding nature of the procedure should not be underestimated. Patients should be cautioned with regard to the possibility of a higher rate of complications than that seen with primary total hip arthroplasty.     

Total knee arthroplasty in nonagenarians

Between 1976 and 1999, 3714 consecutive primary total knee arthroplasties (TKAs) were done at our institution. Of these, 20 (0.54%) TKAs were done in 18 patients who were > or =90 years old. The average follow-up period was 62.2 months. There was 1 postoperative death among the nonagenarians within 90 days of surgery. All patients had complete pain relief and excellent knee scores using the Knee Society clinical assessment scale. None had an excellent function score at final follow-up examination, however. Only 1 patient experienced any surgical complications; the patient had wound dehiscence. Five (26.3%) of the surviving 19 patients had medical complications. The average length of hospital stay was 10.1 days. Although TKA produced only moderate improvement in knee function for the nonagenarians, it produced excellent clinical improvement. TKA improved the patients' ability to manage the activities of daily living and their quality of life.     

Monoclonal antibody from vasectomized mouse identifies a conserved testis-specific antigen TSA70

Vasectomy results in the occlusion of testicular outflow, leading to autoimmunity characterized by the production of antisperm antibodies (ASA). Reports on the rise in ASA following vasectomy in several species are available; however, not much is known about the specific sperm autoantigens to which postvasectomy antibodies are directed. In the present study, monoclonal antibodies were generated using a vasectomized mouse. One of the monoclonal antibodies, D5E5, identified an approximately 70-kd antigen localized on the principal piece of the tail and also on the tip of the acrosome of mouse sperm. The cognate antigen was expressed postmeiotically in a stage-specific manner during spermiogenesis, starting from step 8 of elongating spermatids during spermiogenesis up to mature spermatozoa. The protein was conserved across the species, as observed by its presence in rat, bull, marmoset, and human sperm. Following capacitation, the antigen on the head was seen to shift to the acrosomal region and was lost after the acrosome reaction. However, the localization on tip of the acrosome still persisted, which indicates that the antigen may play a role post-acrosome reaction in sperm egg interaction. Resistance to Triton X-100 solubilization indicates that TSA70 could be an acrosomal matrix protein. In addition, we observed a significant reduction in forward progressive motility of mouse sperm treated in vitro with D5E5. In view of its testis specificity, acrosome and tail localization, and conserved nature, TSA70 is likely to play an important role in sperm function.