Airway problems caused by hypogonadism in male patients undergoing neurosurgery

Unanticipated difficult endotracheal intubations can pose challenges for the anesthesiologist. Risks include airway injury, hypoxemia, and death. There is intubation difficulty in various conditions including Downs syndrome, achondroplasia, acromegaly, and dwarfism. We describe difficulty in intubating the trachea with an appropriate sized endotracheal tube in two young male patients with hypogonadism presenting for neurosurgical procedures under general anesthesia. We discuss the role of hypogonadism and the effects of gonadotropin hormones on pubertal laryngeal growth in male patients.     

Severe hypothyroidism after coronary artery bypass grafting

A 56-year-old man with unstable angina underwent urgent coronary artery bypass grafting. The patient required reintubation and prolonged ventilation because of persistent drowsiness and hypotension. The patient was weaned off the ventilator and extubated; however, he remained drowsy and lethargic. Neurologic examination, electroencephalogram, and computed tomography scan of the brain did not show any organic cause of his depressed neurologic status. His metabolic profile revealed severe hypothyroidism. The patient responded well to oral thyroxine. We report the unusual manner in which hypothyroidism presented in the patient. A high index of suspicion is required to diagnose and treat this complication.     

“Ambulatory PCNL” (Tubeless PCNL under Regional Anesthesia) – A Preliminary Report of 10 Cases

Aim: We report the technique, safety, outcome and efficacy of “tubeless percutaneous nephrolithotomy (PCNL) performed under regional anesthesia” in selected cases. Methods: Patients satisfying the entry criteria for the regional block (spinal low-dose anesthesia with low-dose Bupivacaine plus Fentanyl) and tubeless procedure were subjected to a tubeless spinal PCNL The patients were followed up the next day for an ultrasonography and an x-ray of the KUB region. Results: All the ten patients were discharged uneventfully the next day (mean hospital stay-40 h). No blood transfusion and postoperative analgesics (mean post op visual analogue pain score was 2.4) were required. The mean time to return of S₁ sensation, motor block and walking were 183,118 and 196.6 min respectively. There was complete stone clearance in all the cases with a mean collection of 14.5 cc was seen on the post op ultrasound. Conclusions: The present cases were reported to highlight that in a select group of patients tubeless PCNL under regional block is technically feasible and viable option. Regional block has the advantage of avoidance of general anesthesia and anaphylaxis due to use of multiple drugs. Tubeless PCNL has the advantage of avoidance of nephrostomy tube related postoperative pain discomfort and urosepsis. This synergistically (spinal + tubeless PCNL) speeds up the recovery, shortens the length of hospitalization and the analgesic requirement.     

Emergency surgery after percutaneous transmitral commissurotomy: operative versus echocardiographic findings, mechanisms of complications, and outcomes

OBJECTIVE: This study was undertaken to determine the clinical profile of patients undergoing emergency surgery after balloon mitral valvotomy, to note operative findings and compare them with those of transthoracic echocardiography, to describe the mechanisms of complications, and to describe outcomes. METHODS: A retrospective study was undertaken of patients requiring emergency surgery after percutaneous mitral valvotomy with an Inoue balloon from January 1990 to December 2003. The data analyzed included demographic variables, causes and clinical presentations of complications, and outcome. In 14 consecutive cases of mitral regurgitation, an observational study comparing the operative findings with echocardiography was also undertaken. RESULTS: In 1388 cases of valvotomy, complications necessitating urgent surgery occurred in 31 cases (2.2%). Acute mitral regurgitation occurred in 23 cases (74.2%), and cardiac tamponade occurred in 8 cases (25.8%). Mitral regurgitation was due to leaflet tearing in all cases: anterior leaflet in 20 cases and posterior leaflet in 3 cases. Hypotension, orthopnea, and pulmonary edema were the clinical presentation for mitral regurgitation. Transthoracic echocardiography underestimated the severity of mitral valve pathology. Bilateral severe commissural fusion and pliable leaflet with paracommissural calcium was seen in anterior leaflet tearing. Cardiac tamponade with hemodynamic compromise occurred as a result of left atrial perforation in 6 cases, right atrial perforation in 1 case, and left ventricular perforation in 1 case. High septal puncture led to atrial perforation. Operative mortality was 9.6%, and low cardiac output developed in 29%. CONCLUSION: Acute mitral regurgitation and cardiac tamponade were the causes of emergency surgery after balloon valvotomy. Transthoracic echocardiography underestimated the severity of valve pathology.     

Rapid implementation of an electronic health record in an academic setting

One of the sources of resistance to the implementation of electronic health records is that it often takes years to roll out a fully functional system. The George Washington University Medical Faculty Associates (MFA) has set a new standard for rapid EHR implementation by bringing 99 physicians and 130 residents and interns live in less than 30 days in a complex academic setting. MFA leveraged a rapid implementation process based on study of previous successful implementations. The rollout plan incorporated aggressive hands-on education, in-person and virtual training modules for self-review, and a leadership triad of physicians, administrators, and information technology experts.     

Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 16: bone graft extenders and substitutes

Despite the large volume of animal data regarding the use of synthetic bone graft substitutes or extenders, there are very few data regarding the use of these substances for fusion in lumbar degenerative disease. The best available data indicate that rhBMP-2 is a viable alternative to autograft bone for interbody fusion procedures. This same substance may also be a viable alternative to autograft for PLF; however, definitive medical evidence is not yet available. There is little, if any, medical evidence to support the use of other biological agents at the present time. As promising new compounds are brought to market, well-designed cohort studies and randomized trials will be required to determine the actual usefulness of these compounds in clinical practice. It is important not to generalize the results obtained with one preparation or application to different preparations or applications. The use of synthetic calcium phosphate ceramics as graft extenders appears to be reasonable in certain situations. The medical evidence available regarding their use is limited and of poor quality. Further study will be required to establish their utility for use in spinal fusion.     

Does passive smoking affect the outcome of grommet insertion in children?

Bilateral myringotomy with insertion of ventilation tube (grommet) is the most common surgical procedure done on children under general anaesthetic. A prospective study was conducted on children undergoing grommet insertion to ascertain any relationship between exposures of passive smoking to the outcome of grommet insertion. Six hundred and six children (with 1174 ears) who underwent grommet insertion for recurrent secretory otitis media were followed up till the grommets were extruded. Thirty-three children (65 per cent), whose mothers smoked when they were pregnant, had bilateral narrow external ear canals. The median survival rate of grommet was 59 weeks in children who were exposed to passive smoking as compared to 86 weeks for non-exposed children and the extrusion rate of grommet was 36 per cent higher at the end of one year if both parents smoked compared to the non-smoking group. Post-extrusion myringosclerosis was 64 per cent if both parents smoked and less than 20 per cent if neither parents smoked. It is concluded that post-operative infection rate, attic retraction, post-extrusion myringosclerosis and permanent perforations of tympanic membrane were more common in children exposed to passive smoking. The study provides further support to professional and governmental advice that passive smoking is harmful.     

Bjornstad syndrome

A 9-month-old boy presented with the complaints of loose motion, vomiting and difficulty in breathing. His scalp hairs were thin, brittle, and sparse and were of differing lengths with twisted appearance. Hair shaft microscopy revealed alternate light and dark segments and twisting of the hair shafts by 180 degrees along the axis. Serum copper levels were normal. The audiological testing revealed bilateral sensorineural hearing loss. Child was diagnosed as a case of Bjornstad Syndrome.