Propofol-ketamine versus propofol-fentanyl for outpatient laparoscopy: comparison of postoperative nausea,emesis, analgesia,and recovery

STUDY OBJECTIVE: To compare postoperative nausea, emesis, analgesia, and recovery between propofol-ketamine and propofol-fentanyl in outpatient laparoscopic tubal ligations with general anesthesia. STUDY DESIGN: Prospective, randomized, blinded study. SETTING: Tertiary-care women's hospital. PATIENTS: 120 ASA physical status I and II ambulatory patients scheduled for elective laparoscopic tubal ligation. INTERVENTIONS: Patients were randomized to two groups to receive either ketamine (1-1.5 mg/kg) or fentanyl (3-5 microg/kg). MEASUREMENTS: Measured variables included total dose of ketamine, fentanyl, propofol, and operating time. Vital signs, pain visual analog scale scores (VAS), nausea VAS, presence of emesis, treatment for nausea and vomiting, pruritus, sedation, and presence of dreaming were recorded on postanesthesia care unit (PACU) admission, PACU discharge, stepdown unit admission, and hospital discharge. Results are expressed as means +/- SD or medians and analyzed using t-test, Chi-square, or Mann-Whitney (p < 0.05). MAIN RESULTS: No differences were noted with respect to propofol dose, operating times, pain or nausea VAS scores, emesis, treatment for nausea and vomiting, pruritus, and sedation on PACU admission, PACU discharge, stepdown unit admission, and hospital discharge. The ketamine group had a higher heart rate, required more pain medication, and had a higher frequency of dreaming on PACU admission than the fentanyl group. These differences became insignificant on PACU discharge. CONCLUSIONS: For outpatient laparoscopic tubal ligations with general anesthesia, propofol-ketamine does not improve postoperative nausea, emesis, analgesia or recovery compared with the propofol-fentanyl combination.     

Radiologic case study. Abrasion chondroplasty mimicking avascular necrosis

Arthroscopic abrasion arthroplasty, subchondral drilling, and microfracture continue to be performed with some frequency in younger patients with focal chondral defects and occasionally for patients with moderate degenerative knee arthritis. The plain radiographic appearance after those procedures may mimic avascular necrosis, but MRI is a sensitive method used to exclude the diagnosis of avascular necrosis and evaluate the extent to which fibrocartilaginous repair tissue has formed. When combined with an appropriate clinical history, dedicated articular cartilage imaging sequences improve the sensitivity and specificity that MRI provides in these patients with chondral knee injuries.     

Preoperative blood volume deficit influences blood transfusion requirements in females and males undergoing coronary bypass graft surgery

STUDY OBJECTIVE: To evaluate whether preoperative blood volume and postoperative blood loss influence blood transfusion in females and males undergoing coronary artery bypass graft (CABG) surgery. DESIGN: Prospective study. SETTING: Anesthesiology department of a teaching hospital. PATIENTS: 57 CABG patients (21 females and 36 males). MEASUREMENTS: Blood volume was determined using the radioactivity dilution method. Preoperatively, each patient received intravenous (IV) injection of 1 mL Albumin I(131) tracer having 25 microcuries of radioactivity. Five-milliliter blood samples were collected at different intervals. From these samples, hematocrit (Hct) value, preoperative total blood volume, red blood cell (RBC) volume, and plasma volume were determined. Postoperatively, some consenting patients received another 1 mL dose of the tracer, and the postoperative blood volumes were determined. If a patient received a blood transfusion, the units of packed red blood cells (PRBCs), platelets, or fresh frozen plasma (FFP) transfused were recorded. For each patient we recorded the gender, age, weight, height, body surface area (BSA), preoperative Hct, duration of surgery, and discharge Hct. RESULTS: Preoperatively, the mean total blood volume, RBC volume, and plasma volume, respectively, were 2095 mL/m(2), 631 mL/m(2), and 1,465 mL/m(2) in females; and 2,580 mL/m(2), 878 mL/m(2), and 1,702 mL/m(2) in males. The preoperative blood volumes were significantly lower (p < 0.01) in females than in males. There was no significant difference between males and females in the extent of blood loss during CABG. Intraoperatively, females received PRBC transfusion of 1.38 units, significantly more (p < 0.01) than the 0.39 units received by males. During the entire hospital stay, females received 4.33 units of PRBC, significantly more than (p < 0.02) the 1.33 units received by males. Significantly more (p < 0.01) females (12 of 21) received intraoperative PRBC transfusion than did males (6 of 36). Multiple logistic regression analysis of the data showed that PRBC transfusion was significantly correlated with the preoperative total blood volume and RBC volume. CONCLUSION: The greater need for blood transfusion in females than in males during CABG is primarily attributable to significantly lower preoperative total blood volume and RBC volume in females.     

Klotho Lacks an FGF23‐Independent Role in Mineral Homeostasis

Fibroblast growth factor‐23 (FGF23) is a bone‐derived hormone regulating vitamin D hormone production and renal handling of minerals by signaling through an FGF receptor/αKlotho (Klotho) receptor complex. Whether Klotho has FGF23‐independent effects on mineral homeostasis is a controversial issue. Here, we aimed to shed more light on this controversy by comparing male and female triple knockout mice with simultaneous deficiency in Fgf23 and Klotho and a nonfunctioning vitamin D receptor (VDR) (Fgf23/Klotho/VDR) with double (Fgf23/VDR, Klotho/VDR, and Fgf23/Klotho) and single Fgf23, Klotho, and VDR mutants. As expected, 4‐week‐old Fgf23, Klotho, and Fgf23/Klotho knockout mice were hypercalcemic and hyperphosphatemic, whereas VDR, Fgf23/VDR, and Klotho/VDR mice on rescue diet were normocalcemic and normophosphatemic. Serum levels of calcium, phosphate, and sodium did not differ between 4‐week‐old triple Fgf23/Klotho/VDR and double Fgf23/VDR or Klotho/VDR knockout mice. Notably, 3‐month‐old Fgf23/Klotho/VDR triple knockout mice were indistinguishable from double Fgf23/VDR and Klotho/VDR compound mutants in terms of serum calcium, serum phosphate, serum sodium, and serum PTH, as well as urinary calcium and sodium excretion. Protein expression analysis revealed increased membrane abundance of sodium‐phosphate co‐transporter 2a (NaPi‐2a), and decreased expression of sodium‐chloride co‐transporter (NCC) and transient receptor potential cation channel subfamily V member 5 (TRPV5) in Fgf23/Klotho/VDR, Fgf23/VDR, and Klotho/VDR mice, relative to wild‐type and VDR mice, but no differences between triple and double knockouts. Further, ex vivo treatment of live kidney slices isolated from wild‐type and Klotho/VDR mice with soluble Klotho did not induce changes in intracellular phosphate, calcium or sodium accumulation assessed by two‐photon microscopy. In conclusion, our data suggest that the main physiological function of Klotho for mineral homeostasis in vivo is its role as co‐receptor mediating Fgf23 action. © 2017 American Society for Bone and Mineral Research.     

Nitrous oxide anxiolysis for elective cesarean section

STUDY OBJECTIVE: To determine if inhaled 40% nitrous oxide (N(2)O) via facemask is an effective anxiolytic in women undergoing elective cesarean section under spinal anesthesia. STUDY DESIGN: Prospective, randomized, double-blinded study. SETTING: Tertiary-care women's hospital. PATIENTS: Sixty American Society of Anesthesiologists physical status I and II patients scheduled for elective cesarean section under spinal anesthesia. INTERVENTIONS: Patients were randomized to 2 groups to receive either 100% O2 via facemask or 40% N2O in O2 via facemask. MEASUREMENTS: Vital signs (blood pressure, heart rate, and oxygen saturation) and measured variables (visual analog scale [VAS] anxiety, VAS pain, and sedation scores) were obtained at specific periods during the procedure (preoperatively, entering the operating room, spinal injection, skin incision, uterine incision, delivery, and at the conclusion of the surgical procedure). In addition, surgical time and delivery time, mean dose and percentage of patients requiring ephedrine or phenylephrine boluses, the emesis rate, and Apgar scores were measured. MAIN RESULTS: No differences were noted with respect to maternal mean blood pressure, heart rate, pulse-oximeter oxygen saturation, and sedation or VAS pain scores during the measured periods. No differences were noted in surgical and delivery times, mean dose, or percentage of patients who required ephedrine or phenylephrine to maintain maternal blood pressure, the emesis rate, or 1- and 5-minute Apgar scores. Mean anxiety scores for the N2O group were significantly lower at the time of spinal injection, skin incision, and uterine incision. Multivariate analysis of variance for high-anxiety patients (> or =50 VAS) revealed significantly lower VAS scores in the N2O group, compared with the O2 group again at spinal injection, skin incision, and uterine incision. CONCLUSIONS: Inhaled 40% N2O via facemask provides effective anxiolysis in women undergoing elective cesarean section under spinal anesthesia in patients with high anxiety (> or =50 VAS) at the time of spinal injection, skin incision, and uterine incision.     

Outcomes following parotidectomy for metastatic squamous cell carcinoma with microscopic residual disease: implications for facial nerve preservation

Background.

Metastatic cutaneous squamous cell carcinoma (SCC) of the parotid is an aggressive disease, requiring combined modality treatment of surgery and adjuvant radiotherapy to achieve cure. This study aims to determine whether facial nerve preservation followed by radiotherapy is a reasonable option in patients with microscopic residual disease involving the facial nerve.

Methods.

One hundred seventy‐six patients with metastatic cutaneous SCC involving the parotid were analyzed.

Results.

In this cohort, 15 patients who underwent nerve‐sparing surgery and adjuvant radiotherapy were found to have involved margins adjacent to the facial nerve. Comparing this group to patients with clear margins showed no difference in local recurrence or survival. Only 3 patients in this group developed local recurrence, and all successfully salvaged by further surgery.

Conclusion.

This study suggests that patients with metastatic cutaneous SCC to the parotid with microscopic residual disease involving the facial nerve and normal function can be successfully treated with a facial nerve–sparing approach and timely postoperative radiotherapy. © 2008 Wiley Periodicals, Inc. Head Neck, 2009     

Incidence of Extensor Digitorum Brevis Manus Muscle

The extensor digitorum brevis manus, a supernumerary muscle in the fourth extensor compartment of the dorsum of the wrist, is a relatively rare anomalous muscle. Extensor digitorum brevis should be included in the differential diagnosis of soft tissue masses on the dorsal aspect of the hand as it may mimic cystic, neoplastic, inflammatory, and infectious masses arising in the dorsum of the wrist. Seventy-two upper limbs of male and female cadavers were dissected and examined to study the pattern of extensor tendons of the index finger. In the present study, we observed three cases (4.2%) of the extensor digitorum brevis manus on the left side. In one cadaver (0.72%), there was an additional tendon arising from the extensor indices which was inserted to the radial side of the dorsal digital expansion of the index finger. The extensor digitorum brevis manus muscle (EDBM), an anatomic variant of the extensor muscle of the dorsum of the hand, is found in approximately 2% to 3% of the population. This variation is, therefore, clinically and surgically relevant because the EDBM may be the only muscle responsible for the independent extension of the second digit. The aim of the present study is to report the incidences of this muscle thereby creating awareness of its existence and of its characteristic appearance to surgeons.     

Predictability model of the need for extracorporeal membrane oxygenation in neonates with meconium aspiration syndrome treated with inhaled nitric oxide

Background

As the use of inhaled nitric oxide (iNO) resulted in a decline in the need for extracorporeal membrane oxygenation (ECMO) in neonates with hypoxic respiratory failure, iNO has become an accepted treatment modality even in non-ECMO centers. However, because not all neonates respond to iNO, the timely identification and transfer of nonresponders to an ECMO center are important.

Objectives

The objective of this study was to identify the risk factors predictive of the need of ECMO in neonates with hypoxic respiratory failure after the first 6 hours of iNO treatment in an ECMO center.

Methods and Patient Population

Forty-nine patients with hypoxic respiratory failure transferred for iNO therapy and potential ECMO during a 2-year period were identified in this retrospective study. None of the patients had received iNO before admission. Strict clinical guidelines were used to standardize lung inflation, cardiovascular support, and iNO administration and weaning and to define treatment failure. The relationship between treatment failure (ie, the need for ECMO) and a set of suspected risk factors after 6 hours of iNO administration was examined by logistic regression analysis.

Results

Twenty-two neonates responded to iNO (non-ECMO group) whereas 27 neonates failed and met ECMO criteria (ECMO group). There was no difference between the 2 groups in demographic data, ventilatory support, air leak syndrome at 6 hours of iNO treatment, and survival to discharge. However, the dose and duration of iNO therapy were predictive of the need for ECMO with an adjusted odds ratio of 1.12 (95% CI, 1.01-1.25; P = .04) and 0.45 (95% CI, 0.27-0.65; P = .0002), respectively.

Conclusions

By the end of the first 6 hours of iNO treatment and under the specific conditions established by the use of the clinical guidelines, the dose and the duration of iNO administration were predictive of the probability for the need of ECMO in this patient population. Thus, one can establish a center-specific predictability model for the need of ECMO in neonates with hypoxic respiratory failure treated with iNO if strict clinical guidelines for iNO administration and weaning and respiratory and cardiovascular support are used in the given center.     

Third-body wear testing of a highly cross-linked acetabular liner: the effect of large femoral head size in the presence of particulate poly(methyl-methacrylate) debris

The hip simulator wear performance of an electron beam cross-linked and subsequently melted ultrahigh molecular weight polyethylene against femoral heads of 28-, 38-, and 46-mm diameter in the presence of poly(methyl-methacrylate) particulate debris was contrasted with that of conventional polyethylene against a 46-mm diameter head. Over 5 million cycles of testing, the average wear rate of the conventional polyethylene liners was 29.3 +/- 3.0 mg per million cycles. All highly cross-linked components exhibited marked reduction in wear, with the highest wear measuring 0.74 +/- 0.85 mg per million cycles. This study, using a clinically relevant third-body material, showed the electron beam cross-linked material to be far more resistant to this third-body wear than conventional ultrahigh molecular weight polyethylene, even when very large diameter femoral heads were used.     

Minimal Acute Rejection after Lung Transplantation: A Risk for Bronchiolitis Obliterans Syndrome

Bronchiolitis obliterans syndrome (BOS) is a major cause of lung allograft dysfunction. Although previous studies have identified mild to severe rejection (grade>or=A2) as a risk factor for BOS, the role of minimal rejection (grade A1) remains unclear. To determine if A1 rejection by itself is a risk factor for BOS, we performed a retrospective cohort study on 228 adult lung transplant recipients over a 7-year period. Cohorts were defined by their most severe rejection episode (none, A1 only, and >or=A2) and analyzed for the subsequent development and progression of BOS using univariate and multivariate time-dependent Cox regression analysis. In the univariate model, the occurrence of isolated minimal rejection was a risk factor for all stages of BOS. Similarly, multivariate models that included HLA mismatch, cytomegalovirus pneumonitis, community acquired viral infection, underlying disease and type of transplant demonstrated that A1 rejection was a distinct risk factor for BOS. Furthermore, the associated risk with A1 rejection was slightly greater than the risk from >or=A2 and treatment of A1 rejection decreased the risk for subsequent BOS stage 1. We conclude that minimal rejection is associated with an increased risk for BOS development and progression that is comparable to A2 rejection.