Low fresh gas flow balanced anesthesia versus target controlled intravenous infusion anesthesia in laparoscopic cholecystectomy: a cost-minimization analysis

BACKGROUND: Laparoscopic surgery is widely recognized as a well-tolerated and effective method for cholecystectomy. It is also considered cost saving because it has been associated with a decreased hospital length of stay. Variables that might lead to increased costs in laparoscopic surgery are the technique and drugs used in anesthesia. OBJECTIVE: The goal of this study was to compare the costs of 2 anesthetic techniques used in laparoscopic cholecystectomy (LC)--balanced versus IV anesthesia--from the standpoint of an outpatient surgical department, with a time horizon of 1 year. METHODS: Patients scheduled to undergo elective LC were enrolled in this prospective case study. Patients were randomly allocated to receive balanced anesthesia, administered as low fresh gas flow (LFGF) with inhalational sevoflurane and IV sufentanil in a target controlled infusion (LFGF SS group), or IV anesthesia, administered as IV propofol/sufentanil in a target controlled infusion (TCI group). We used a microcosting procedure to measure health care resource utilization in individual patients to detect treatment differences. The costs of medications used for the induction and maintenance of anesthesia during surgery were considered for LFGF SS and TCI. Other end points included duration of anesthesia; mean times to early emergence, tracheal extubation, orientation, and postanesthesia discharge (PAD); pain intensity before first analgesia; number of analgesics required in the first 24 hours after surgery; and prevalences of nausea, vomiting, and agitation. RESULTS: A total of 60 patients were included in this analysis (male/female ratios in the LFGF SS and TCI groups: 11/19 and 12/18, respectively; mean [SD] ages, 48 [7.9] and 47 [8.6] years; and mean [SD] body mass indexes, 26 [2.0] and 26 [3.0] kg/m2). The costs of anesthetics were significantly lower with LFGF SS compared with TCI (euro17.40 [euro2.66] vs euro22.01 [euro2.50] [2006 euros]). Times to early emergence and tracheal extubation were significantly shorter with LFGF SS than TCI (5.97 [1.16] vs 7.73 [1.48] minutes and 7.57 [1.07] vs 8.87 [1.45] minutes, respectively). There were no significant between-group differences in mean duration of anesthesia; times to orientation and PAD; pain intensity before first analgesia; number of analgesics required in the first 24 hours; or prevalences of nausea, vomiting, and agitation. Because no clinically significant differences in the anesthetic results were observed, a cost-minimization analysis was conducted and found that using LFGF SS, the outpatient surgical department could realize a budget savings of euro454 per 100 patients. For the nearly 1000 expected patients per year, the savings for the department was calculated as euro4540. CONCLUSION: The results from this cost analysis in these patients who underwent elective LC suggest that the use of sevoflurane through the LFGF technique would be cost saving in this outpatient surgical department.     

EPSP depression following neocortical seizures in cat

To study the possible mechanism(s) underlying unresponsiveness following neocortical seizures, we recorded excitatory postsynaptic potentials (EPSPs) of cortical neurons evoked by ipsilateral cortical stimulation before and after spontaneous or elicited seizures. Regular-spiking neurons (n = 32) were intracellularly recorded in association area five of cats under ketamine-xylazine or barbiturate anesthesia. Compared with control responses, cortically evoked EPSPs were characterized by decreased amplitude after electrographic seizures. Synaptic responses and intrinsic properties were measured by applying extracellular electrical stimuli followed by intracellular hyperpolarizing current pulses. The input resistance decreased during seizures but quickly recovered to control level after the paroxysms, whereas the amplitude of evoked EPSPs remained lower following seizures, generally for 2-12 min, suggesting that the decreased EPSPs were not due to an alteration of intrinsic response. Data demonstrate a long-lasting decreased synaptic responsiveness following generalized spike-wave seizures slowly recovering in time.     

Right Ventricular Electrical and Mechanical Synchronization by Properly Timed Septal Pacing in a Patient with Right Bundle Branch Block and First Degree AV Block—A Case Report

We present a case of near‐normalization of the QRS by septal pacing in a patient with dual‐chamber pacemaker and underlying complete right bundle branch block and first degree atrioventricular block. The right ventricular mechanical synchronization suggested by the ECG was validated as such by strain echo. To the best of our knowledge, this is the first time it has been shown that the narrowing of the QRS corresponds to mechanical synchronization in a case of this seldom‐recognized phenomenon.     

Lipids profile in a group of hypothyroid patients vs. treated hypothyroid patients

Hypothyroidism, like obesity, is one of the pathological conditions most frequently associated to disorders of the lipid metabolism. Hypercholesterolemia is favored, due to the hormone deficit and to the decreased activity of the lipoprotein lipase. MATERIALS AND METHOD: We observed the determination of the serum concentrations of TSH, of the total cholesterol level, of the triglycerides, HDL, LDL, VLDL and BMI as well. RESULTS AND DISCUSSIONS: We observed the predominance of the female hypothyroid patients, ages 40 through 60 and BMI > 30kg/m2. The presence of the heart condition in the studied group was the predominance of the cases of ischemic heart disease. The cholesterol levels varied depending on the TSH levels. There are multiple mechanisms of the dyslipemic syndrome, its intensity depending on the degree of the thyroid insufficiency, however, not influenced being by its cause. It can be considered an indicator of the disease evolution or of the efficiency of the substitution treatment strategy. The absence of the total normalization of the lipid metabolism, under the conditions of a correct treatment strategy, may raise suspicions regarding a possible associated primitive hyperlipidemia, who need typical therapy.     

Omalizumab for successful chemotherapy desensitisation: What we know so far

BackgroundHypersensitivity reactions induced by chemotherapeutic drugs may influence the course of the oncologic disease by preventing doctors from prescribing first‐line therapy. In order to prevent another hypersensitivity reaction to the culprit chemotherapeutic agent, the physician can decide between two possibilities: premedication or desensitisation protocols. Rapid drug desensitisation showed successful results for most patients, but some of them may develop symptoms. Although omalizumab is not licensed as premedication or adjuvant therapy in chemotherapy desensitisation protocols, there have been published some case reports and small sample size studies that indicated promising results.MethodsWe reviewed all the published literature regarding the use of omalizumab during chemotherapy desensitisation protocols.Results and conclusionsWe found a great heterogeneity between the doses and the interval between omalizumab injections and chemotherapy ‐ rapid drug desensitisation, but most of the studies showed promising results. As a corollary, we propose a dose regimen of omalizumab administered before the first desensitisation protocol. Then, omalizumab should be administered one day before every chemotherapy regimen. Omalizumab might be used as an adjuvant therapy and might be a solution for a hopeless situation.     

Loupes-only microsurgery

Standard magnification in microsurgery is accomplished with the operating microscope. Loupes are perceived by the microsurgical community as technically less safe. However, after several years of microscope-only microsurgery, most of our microvascular procedures are performed under loupes 3.5-4x. Considering our results using loupes-only microsurgery, which are comparable with those obtained when using the microscope, we suggest that loupe-aided microsurgery might represent a natural progression for the experienced microsurgeon. Microsurgical skills and experience outweigh the importance of the magnification factor. While the microscope is mandatory for replantations distal to the palmary arch, microneurosurgery, and supramicrosurgery, loupes should be used in so-called "macro-microsurgery." One may include in this category replantations down to the palmar arch and free flaps with vessels more than 1.5 mm, such as the latissimus, serratus, (para)scapular, fibula, radial forearm, rectus abdominis, dorsalis pedis, omentum, and jejunum. Before starting loupes-only microsurgery, intensive training under the microscope is crucial. Less magnification does not mean less quality.     

Discovery of natural naphthoquinones as sortase A inhibitors and potential anti-infective solutions against Staphylococcus aureus

Three natural naphthoquinones were screened to find new anti-virulence agents as inhibitors against sortase A from Staphylococcus aureus (SaSrtA) by quantifying the increase in fluorescence intensity upon substrate cleavage at various concentrations. The 5-hydroxy-1,4-naphthalenedione derivatives, juglone and plumbagin, demonstrated a potent inhibitory effect, with IC₅₀ values of 1.78 μM, respectively, 16.71 μM. The related 2-hydroxy-1,4-naphthalenedione derivative, lawsone, demonstrated the selectivity of the chemical scaffold having no significant effect on SaSrtA. The experimental assay was reinforced by molecular docking experiments, antimicrobial, and toxicological studies. Molecular docking studies and the electrophilic character analysis suggest bonding to the enzyme active cysteine residue by a Michael addition reaction. None of the compounds had a significant effect on the concentration of total thiol proteins in the Daphnia magna toxicological assay after 24 hr exposure. Juglone and plumbagin moderately inhibited biofilm formation with no significant effect on bacterial growth of S. aureus, Enterococcus faecalis, and Staphylococcus epidermidis, indicating a selective anti-virulence profile.     

Catastrophic mitral prosthesis dehiscence diagnosed by three‐dimensional transesophageal echocardiography

In emergency situations, real‐time three‐dimensional transesophageal echocardiography (RT 3‐dimensional TEE) may provide unique anatomic insights on prosthetic valves when two‐dimensional imaging is inconclusive. We report the case of a 76‐year‐old woman, in cardiogenic shock, who had undergone mitral valve replacement 3 months ago. RT 3‐dimensional TEE revealed almost total, catastrophic prosthesis dehiscence following infective endocarditis, the prosthesis being perpendicular to the normal mitral plane. Corrective surgery was not feasible, and the patient died shortly after admission. Although the outcome was unfortunate, RT 3‐dimensional TEE helped rapidly reach a definitive diagnosis, essential for decision‐making. Three‐dimensional TEE should be used as a complementary technique in difficult cases. © 2013 Wiley Periodicals, Inc. J Clin Ultrasound 42:249–251, 2014