Successful resuscitation of serious bupivacaine intoxication in a patient with pre-existing heart failure

PURPOSE: In dogs intoxicated with bupivacaine, clonidine is effective to treat conduction disturbances and dobutamine corrects myocardial depression. We report the case of a patient who experienced severe bupivacaine cardiotoxicity and who was treated successfully using these medications. CLINICAL FEATURES: In a patient with pre-existing heart failure a surgical procedure to fix a humeral fracture was necessary. Preoperatively, heart failure was controlled with transcutaneous nitroglycerin and iv deslanoside. A bupivacaine bolus was administered iv accidentally (a mixture of bupivacaine 75 mg, 15 micro g clonidine). The patient developed nodal rhythm with extreme bradycardia, severe shock and convulsions. Seizures were controlled with thiopentone/succinylcholine. Epinephrine iv boluses (0.1 mg x 3) restored blood pressure (BP) to 50/30 mmHg and heart rate (HR) to 60 (nodal rhythm). Following 75 micro g clonidine iv, BP rose to 90/70 and HR to 90 min. Cardiac rhythm reverted to sinus rhythm with first degree atrio-ventricular block. Echocardiography showed hyperkinesia and relative hypovolemia that was controlled with iv administration of terlipressin and glucagon. Subsequent dobutamine infusion stabilized hemodynamic conditions. It was decided to proceed with surgery using a midazolam/sufentanil based general anesthetic. In the intensive care unit, recovery, extubation and weaning from the dobutamine infusion were realized within 16 hr of the event. CONCLUSIONS: In this patient with preoperative heart failure, clonidine was effective to treat bupivacaine induced conduction disturbances. Epinephrine and dobutamine were effective to treat myocardial depression and terlipressin effectively controlled vasodilatation.     

Comparing the Effect of a Resin Based Sealer on Crown Retention for Three Types of Cements: An In Vitro Study

To determine the effect of resin based sealer on retention of casting cemented with three different luting agents. 55 extracted molar teeth were prepared with a flat occlusal surface, 20° taper and 4 mm axial height. The axial surface of each specimen was determined. The specimen were then distributed into five groups based on decreasing surface area, so each cementation group contained 11 specimens with similar mean axial surface area. A two-step, single bottle universal adhesive system (One-Step—Resinomer, Bisco) was used to seal dentin after the tooth preparation. Sealer was not used on the control specimens except for the modified-resin cement (Resinomer, Bisco) specimens that required use of adhesive with cementation. Using ceramometal (Wirobond^®, BEGO), a casting was produced for each specimen and cemented with either zinc phosphate (Harvard), glass ionomer (Vivaglass) or modified resin cement (Resinomer) with single bottle adhesive. All the castings were cemented with a force of 20 kg. Castings were thermal cycled at 5 and 55 °C for 2,500 cycles and were then removed along the path of insertion using a universal testing machine at 0.5 mm/min. A single-factor ANOVA was used with a = 0.05. The nature of failure was also recorded. The mean stress removal for non sealed zinc phosphate, sealed zinc phosphate, non sealed glass ionomer, sealed glass ionomer and modified resin cement was found to be 3.56, 1.92, 2.40, 4.26, 6.95 MPa respectively. Zinc phosphate cement remained principally on the castings when the tooth surface was treated with the sealer and was found on both the tooth and the casting when the sealer was not used. Fracture of root before dislodgement was seen in 9 of 11 specimens with modified resin cement. Resin sealer decreases the retention of the castings when used with zinc phosphate and increases it when used with glass ionomer cement. The highest mean dislodgement force was measured with modified resin cement.     

Treatment with Lavender Aromatherapy in the Post-Anesthesia Care Unit reduces Opioid Requirements of Morbidly Obese Patients Undergoing Laparoscopic Adjustable Gastric Banding

BACKGROUND: Parenteral administration of opioids and NSAIDs has been the mainstay for postoperative pain control in patients undergoing laparoscopic adjustable gastric banding (LAGB). Both classes of drugs, however, are associated with serious adverse effects. An addition of complimentary analgesic techniques may decrease requirement for traditional analgesics, thus reducing the incidence of side-effects. We designed the study to evaluate the effectiveness of Lavender aromatherapy in reducing opioid requirements after LAGB. METHODS: A prospective randomized placebo controlled study was carried out on 54 patients undergoing LAGB. Upon arrival to the post-anesthesia care unit (PACU), patients in the study group were treated with lavender oil, which was applied to the oxygen face mask; the control group patients received nonscented baby oil. Postoperative pain was treated with morphine. Numerical rating scores (0-10) were used to measure the level of pain at 5, 30, and 60 min. Sedation was evaluated using the Observer Assessment of Alertness/Sedation scale (0-5). Data analyzed included the amount of opioids, NRS, OAA/S, PACU discharge time, as well as the incidence of side-effects. RESULTS: The two groups were comparable with regard to patient characteristics, intraoperative drug use, and surgical time. Significantly more patients in the Placebo group (PL) required analgesics for postoperative pain (22/27, 82%) than patients in the Lavender group (LAV) (12/26, 46%) (P = .007). Moreover, the LAV patients required significantly less morphine postoperatively than PL patients: 2.38 mg vs 4.26 mg, respectively (P = .04). There were no differences in the requirements for post-operative antiemetics, antihypertensives, or PACU discharge time. CONCLUSIONS: Our results suggest that lavender aromatherapy can be used to reduce the demand for opioids in the immediate postoperative period. Further studies are required to assess the effect of this therapy on clinically meaningful outcomes, such as the incidence of respiratory complications, delayed gastric emptying, length of hospital stay, or whether this therapy is applicable to other operations.     

QUANTITATIVE EXPRESSION OF HLA CLASS I MOLECULES IN ACUTE NON-LYMPHOBLASTIC LEUKAEMIA CELLS

The present study concerns a panel of 33 acute non lymphoblastic leukaemia (ANLL) patients, previously typed for HLA-A,B serological specificities and including samples with a normal HLA-A,B phenotype (3,4 detected specificities) as well as samples with missing and extra specificities. Samples were analysed at the protein and/or RNA level in order to verify whether the observed typing anomalies were due to a modified quantitative expression of class I molecules. The number of HLA-A.B assigned specificities correlated significantly with the cell surface class I expression detected by indirect immunofluorescence using the monomorphic anti-class I MoAb W6/32 (Spearman rank correlation test, P < 0.01) and with the amount of class I Heavy Chain (HC, P < 0.05) and beta-2-microglobulin (β2m, P < 0.05) evaluated by Western blot in whole cell extracts. The RNA analysis suggested a HC-β2m coordinated down regulation at the mRNA level in a patient with no assigned HLA-A,B specificities. Another patient with no detectable HLA-A,B specificities showed a low expression selectively of the β2m protein. The results reported here demonstrate a heterogenous quantitative HLA class I expression in ANLL blasts, analogous to results reported for solid tumours.     

Fiber-optic intubation with non-invasive ventilation with an endoscopic facial mask

OBJECTIVES: To assess the feasibility and safety of a new technique of fiberoptic bronchoscopy (FOB) tracheal intubation (TI) with noninvasive ventilation (NIV) via an endoscopic full facial mask with two openings, in case of acute respiratory failure (ARF) temporally improved by NIV, but requiring a mechanical ventilation. STUDY DESIGN: Clinical, prospective, open, noncomparative trial of feasibility with direct individual profit. PATIENTS: Sixteen patients with ARF (age: 60 +/- 17 years, PaO2 = 59 +/- 16 mmHg, PaCO2 = 64 +/- 26 mmHg, PaO2/FIO2 = 142 +/- 70 before NIV) (m +/- SD), requiring TI. Including were: TI necessity (SpO2 < 90% or hypercapnic despite NIV, dependence of NIV, exhaustion, septic syndrome), clinical and SpO2 improvement with NIV. METHODS: After i.v. injection of 5 mg midazolam and topical anesthesia (TA) of the nose, the endoscopic mask (modified Fibroxy, Péters) was applied to the face, fixed with elastic straps, then connected to the ventilatory support system with IPAP = 20 cmH2O, EPAP = 5 to 12 cmH2O, FIO2 = 1. A tube was slid on the FOB. As soon as SpO2[[[nbsp] 94%, the extremity of the FOB, was inserted through the lower opening of the mask, slid in the nostril, positioned in front of the glottis for AL, then pushed in the trachea authorizing AL and i.v. injection of 0.15 mg.kg-1 of etomidate (Ramsay[[[nbsp]3). The tube was then slid in the trachea, then, FOB was removed from trachea. RESULTS: The FOB intubation was easy at the patient's, without any failure or any complication. The procedure was 6.7 +/- 2 min. SpO2 significantly improved during TI, from 84 +/- 5% (FIO2 = 0.6 +/- 3) to 97 +/- 1 (FIO2 = 1 +/- 0), without decrease in oxygen saturation off 90%. Arterial pressure decreased only after the 5th min. The quantities of midazolam and of etomidate used were 4.6 +/- 2 mg and 12 +/- 4 mg. Three patients benefited from EPAP > 10 cmH2O. CONCLUSION: Fiberoptic tracheal intubation with NIV via an adapted endoscopic facial mask is a safe technique in patient with ARF temporally improved by NIV. This procedure requires TA and conscious sedation.