Major complications related to epidural analgesia in children: a 15-year audit of 3,152 epidurals

Background

Complications associated with epidural analgesia in children have a reported incidence of 40-90 in 10,000 epidurals. We sought to determine the incidence of major complications with the use of continuous epidural analgesia that occurred in our centre over the past 15 years and to describe the nature of these complications.

Methods

The Acute Pain Service database at a tertiary care academic pediatric hospital was reviewed retrospectively over a 15-year period. Data were categorized according to patient age (neonate, infant, child one through eight years, and child > eight years), mode of insertion of the epidural (caudal, transsacral, lumbar, thoracic), complication type, and complication severity.

Results

Over the 15-year period, 3,152 epidurals were performed. The use of caudal-thoracic epidurals in neonates and infants has increased since 2007. Twenty-four major complications were identified (incidence, 7.6 in 1,000 epidurals). The rate of complications in neonates was 4.2% compared with 1.4% in infants, 0.5% in children aged one through eight years, and 0.8% in children over eight years of age. The two most common complications were local skin infection and drug error.

Conclusions

Our incidence of major complications and our finding that complications were more common in neonates and infants are both consistent with previously published data. The two most common types of complications are potentially preventable.     

Proper preparation to reduce endoscopic reexamination due to food residue after distal gastrectomy for gastric cancer

Background

Reducing food residue by proper preparation methods before endoscopy after distal gastrectomy can increase the quality of examination and decrease patient discomfort. We evaluated the risk factors for food residue and proper methods of preparation for endoscopy after distal gastrectomy.

Methods

Follow-up endoscopy with questionnaires was performed on 1,001 patients who underwent distal gastrectomy at Asan Medical Center between December 2010 and July 2011.

Results

Endoscopic examination failed in 94 patients (9.4 %) as a result of large amounts of food residue. Rates of failure were significantly higher in patients who ate a regular diet rather than a soft diet at last dinner before examination (13.9 vs. 6.1 %, p = 0.050), and in those who ate lunch rather than not eating lunch on the day before examination (14.6 vs. 7.7 %, p = 0.020). Multivariate analysis showed that the rate of failed examination was lower in patients who had a history of abdominal surgery (p = 0.011), those who ate a soft (p < 0.001) or liquid (p = 0.003) diet as a last meal rather than a regular diet, those who underwent Billroth I rather than Billroth II reconstruction (p = 0.035), patients with longer fasting time (p = 0.009), and those with a longer gastrectomy-to-endoscopy time interval (p < 0.001).

Conclusions

Patients who undergo follow-up endoscopy after surgery should fast more than 18 h and ingest a soft or liquid diet on the day before examination.     

How Long Will I Be Blue? Prolonged Skin Staining Following Sentinel Lymph Node Biopsy Using Intradermal Patent Blue Dye

Zusammenfassung

Hintergrund: Der für die Sentinel-Knoten-Biopsie bei Mammakarzinom-Patientinnen verwendete blaue Farbstoff kann längerfristige Hautverfärbungen im Injektionsbereich verursachen. Ziel dieser Studie war es, die Dauer derartiger Hautverfärbungen zu bestimmen. Patientinnen und Methoden: 236 aufeinanderfolgende Mammakarzinom-Patientinnen, bei denen eine brusterhaltende Operation und Sentinel-Knoten-Biopsie durchgeführt worden waren, wurden von Januar 2007 bis Dezember 2009 prospektiv untersucht. Ergebnisse: Bei 2 der 236 Patientinnen war eine bilaterale chirurgische Behandlung erfolgt, und 41 wurden im Rahmen jährlicher Nachuntersuchungen beurteilt. Blaue Verfärbungen im Injektionsbereich waren nach 12, 24 bzw. > 36 Monaten bei 36,5, 23,6 bzw. 8,6% der Patientinnen weiterhin sichtbar. Schlussfolgerung: Die Anwendung von Patentblau zur Identifikation des Sentinellymphknotens bei chirurgisch behandelten Mammakarzinom-Patientinnen kann zur längerfristigen Verfärbung der Haut im Injektionsbereich führen.     

The NORwegian study on DIstrict treatment of ST-Elevation Myocardial Infarction (NORDISTEMI)

Objectives. Thrombolysis is the treatment of choice for patients with ST-elevation myocardial infarction (STEMI) living in rural areas with long transfer delays to percutaneous coronary intervention (PCI). This trial compares two different strategies following thrombolysis: to transfer all patients for immediate coronary angiography and intervention, or to manage the patients more conservatively. Design. The NORwegian study on DIstrict treatment of STEMI (NORDISTEMI) is an open, prospective, randomized controlled trial in patients with STEMI of less than 6 hours of duration and more than 90 minutes expected time delay to PCI. A total of 266 patients will receive full-dose thrombolysis, preferably prehospitally, and then be randomized to either strategy. Our primary endpoint is the one year combined incidence of death, reinfarction, stroke or new myocardial ischaemia. The study is registered with ClinicalTrials.gov, number NCT00161005. Results. By April 2006, 109 patients have been randomized. Thrombolysis has been given prehospitally to 52% of patients. The median transport distance from first medical contact to catheterization laboratory was 155 km (range 90–396 km). Results of the study are expected in 2008.

Trial registration: ClinicalTrials.gov identifier: NCT00161005.     

Suture button suspension following trapeziectomy in a cadaver model

Background

The safety and the effects of different trajectories on thumb motion of suture-button suspensionplasty post-trapeziectomy are not known.

Methods

In a cadaveric model, thumb range of motion, trapeziectomy space height, and distance between the device and nerve to the first dorsal interosseous muscle (first DI) were measured for proximal and distal trajectory groups. Proximal trajectory was defined as a suture button angle directed from the thumb metacarpal to the second metacarpal at a trajectory less than 60° from the horizontal; distal trajectory was defined as a suture button angle directed from the thumb metacarpal to the second metacarpal at a trajectory of greater than 60° from the horizontal (Fig. 1).

Results

There were no significant differences in range of motion and trapeziectomy space height between both groups. The device was significantly further away from the nerve to the first DI in the proximal trajectory group compared to the distal trajectory group, but was still safely away from the nerve in both groups (greater than 1 cm).

Conclusions

These results suggest that the device placement in either a proximal or distal location on the second metacarpal will yield similar results regarding safety and thumb range of motion.     

A SIX-CENTRE INTERNATIONAL STUDY OF THE OUTCOME OF TREATMENT IN PATIENTS WITH CLEFTS OF THE LIP AND PALATE: THE RESULTS OF A CROSS-LINGUISTIC INVESTIGATION OF CLEFT PALATE SPEECH

During the period 1964–73, 286 patients were treated for mandibular fractures. 229 patients (80%) attended the follow-up examination. The length of observation was from 1 to 9 years. The treatment and the follow-up evaluations in the 229 patients are described. Early fracture treatment has been the objective, also in patients who have undergone severe cerebral traumas. Antibiotic prophylaxis was implemented in cases of compound fractures. Preservation of teeth and tooth buds in the line of fracture was attempted. Clinical infection occurred in 0.4% of the patients. At the follow-up examination 1 patient presented with a fracture displacement outside the condylar process. Neither malocclusion nor pseudarthrosis following fracture or after treatment were seen. Permanent sensory disturbances in the innervation area of the mental nerve following fracture occurred in 8%. Radiological examination of the teeth in the line of fracture revealed unnoticed apical bone lesions in 17% of 118 patients. In a further 23% there was a negative response to the vitality test. Follow-up control of mandibular fractures is advised at 12 to 18 months after treatment.     

Symmetrically reduced stiffness and increased extensibility in compression and tension at the mineralized fibrillar level in rachitic bone

In metabolic bone diseases, the alterations in fibrillar level bone-material quality affecting macroscopic mechanical competence are not well-understood quantitatively. Here, we quantify the fibrillar level deformation in cantilever bending in a mouse model for hereditary rickets (Hpr). Microfocus in-situ synchrotron small-angle X-ray scattering (SAXS) combined with cantilever bending was used to resolve nanoscale fibril strain in tensile- and compressive tissue regions separately, with quantitative backscattered scanning electron microscopy used to measure microscale mineralization. Tissue-level flexural moduli for Hpr mice were significantly (p < 0.01) smaller compared to wild-type (~ 5 to 10-fold reduction). At the fibrillar level, the fibril moduli within the tensile and compressive zones were significantly (p < 0.05) lower by ~ 3- to 5-fold in Hpr mice compared to wild-type mice. Hpr mice have a lower mineral content (24.2 ± 2.1 Ca wt.% versus 27.4 ± 3.3 Ca wt.%) and its distribution was more heterogeneous compared to wild-type animals. However, the average effective fibril modulus did not differ significantly (p > 0.05) over ages (4, 7 and 10 weeks) between tensile and compressive zones. Our results indicate that incompletely mineralized fibrils in Hpr mice have greater deformability and lower moduli in both compression and tension, and those compressive and tensile zones have similar moduli at the fibrillar level.