A randomized, double blind, placebo-controlled study to investigate the use of conscious sedation in conjunction with paracervical block for reducing pain in termination of first trimester pregnancy by suction evacuation

BACKGROUND: This study evaluated the role of conscious sedation in pain relief during termination of first trimester pregnancy by suction evacuation (SE) under local anaesthesia. METHODS: A hundred women undergoing SE before 12 weeks gestation were randomized by computer using the sealed envelope method to receive placebo (saline) or conscious sedation (2 mg midazolam and 25 microg fentanyl) i.v. 5 min before cervical dilatation. Paracervical block was given to all patients, 2 min later. Pain scores during and after SE, post-operative side-effects and satisfaction level were compared. RESULTS: No statistically significant differences in pain scores were found between the two groups. Post-operative side-effects such as dizziness (P = 0.015) and drowsiness (P < 0.001) were significantly more severe in the conscious sedation group. However, patients in the conscious sedation group reported better satisfaction levels than the control group (P = 0.003). CONCLUSION: The use of conscious sedation significantly improved patient satisfaction during termination of first trimester pregnancy by SE under local anaesthesia, despite a lack of improvement in pain relief and the presence of increased severe dizziness/drowsiness in the post-operative period.     

Off-clamp Retroperitoneoscopic Tumour Evacuation for Sporadic Renal Angiomyolipomas with High RENAL Nephrometry Scores: A Novel Surgical Technique and Its Outcomes

BackgroundPartial nephrectomy or angioembolisation is commonly used for sporadic renal angiomyolipomas (RAMLs) with high RENAL scores, but there is a risk of reduced renal function, postoperative complications, and recurrence.ObjectiveTo describe a new technique for off-clamp laparoscopic evacuation of sporadic RAMLs with high RENAL scores that promotes maximal renal function maintenance and low postoperative complication and lesion recurrence rates.Design, setting, and participantsA retrospective cohort of patients undergoing off-clamp laparoscopic evacuation for sporadic RAMLs with RENAL scores ≥9 from January 2013 to June 2018 was included.Surgical procedureWe highlighted the curettage, suction, packing, and binding (CSPB) technique, a new off-clamp retroperitoneoscopic evacuation technique for sporadic RAMLs.MeasurementsDemographics, preoperative, intraoperative, and postoperative outcomes were assessed.Results and limitationsA total of 141 cases were included. The median (interquartile range [IQR]) tumour size was 7 (6.2–8.2) cm. The median (IQR) RENAL score was 10 (9–11). The median (IQR) operative time was 80 (65–125) min, with a median (IQR) estimated blood loss of 130 (90–362.5) ml. Conversion to neither open surgery nor standard laparoscopy occurred. The warm ischaemia time was zero for all cases. Postoperatively, 13 minor complications (Clavien grade 1) were recorded. No blood transfusions were reported. The glomerular filtration rate did not change significantly from preoperative period to 12-mo follow-up. Recurrence did not occur at the median follow-up period of 48 (36–60) mo. The retrospective design and lack of a control group are limitations of this study.ConclusionsOff-clamp retroperitoneoscopic tumour evacuation using the CSPB technique is feasible, safe, and effective for treating complex sporadic RAMLs.Patient summaryWe report a curettage, suction, packing, and binding technique for off-clamp retroperitoneoscopic evacuation of sporadic renal angiomyolipomas that leads to complete lesion clearance, excellent renal function preservation, and minimal perioperative complications.     

Mechanical dilation to remove incarcerated laminaria during a second trimester abortion

Cervical preparation with laminaria reduces complications with 2nd trimester dilation and evacuation. During a surgical abortion at 22 weeks, we could not remove laminaria manually or with ring forceps due to laminaria “dumbbelling” [1]. Without pushing laminaria into the uterus, we mechanically dilated the cervix and removed the incarcerated laminaria.     

Use of a pulse oximeter for determination of systolic blood pressure in a helicopter air ambulance

INTRODUCTION: Traditional methods of determining blood pressure may be unreliable (auscultation or palpation) or unavailable (direct arterial cannulation) in the air medical environment. The authors investigated the combination of a pulse oximeter with a standard sphygmomanometer (blood pressure) cuff as an alternative method. METHOD: The pulse oximeter is applied to a finger on the same upper extremity on which a standard blood pressure cuff had been applied. A baseline blood pressure was obtained by palpation or an automated blood pressure device. One minute later, the systolic blood pressure (SBP) was determined by inflating the blood pressure cuff until the pulsatile display on the pulse oximeter was obliterated. This was taken as the systolic blood pressure. RESULTS: Complete data were obtained on 116 patients, with 223 data pairs. The SBP as obtained by the baseline method was strongly correlated with the SBP obtained by the pulse oximeter display obliteration method (r = 0.90, p < 0.001). CONCLUSION: The obliteration of the wave form display on a pulse oximeter is an accurate, convenient, inexpensive and readily available alternative method of determining SBP.     

Training of flight nurses on fixed-wing air ambulance services

Introduction: The purpose of this study was to determine the background of fixed-wing air ambulance nurses, what level of training they receive before assignment as a flight nurse, and how closely supervised these fixed-wing air ambulance programs are by their medical directors.

Methods: In 1993, a retrospective statistical questionnaire was sent to 113 fixed-wing air ambulance programs. Chief flight nurses for all 113 fixed-wing air ambulance transport companies were requested to complete a written survey consisting of 17 multiple choice and fill-in-the-blank questions about previous experience, flight nurse qualifications, and content covered in their initial training program.

Results: Of 113 surveys, 72 (64%) responded. The majority (87%) of the flight crew were 30 to 39 years of age. The crew mix is RN/EMT-P in 49%, RN/RN in 25%, and RN/RT in 25%. Experience before flying showed emergency department/intensive care unit in 87% with 13% specialized to a specific type of patient care. The initial training in classroom hours was less than 21 hours in 50% of programs. Training programs were taught by the chief flight nurse in 75%, the medical directors in 74%, and outside organizations in 30%. Fifty-five percent of programs use pilots or other flight crew members to supplement initial training. Only eight of the programs did not have yearly refresher classes. Programs providing more extensive training appear to be affiliated with hospital-based services. Medical directors were involved with the everyday running of air medical transports in 35 of the pro grams (50%), 20 medical directors (28%) did monthly chart reviews only, and 12 (17%) were not involved with their programs. There were three responses to “Other” and two with no responses.

Conclusions: Although fixed-wing flight nurses appear to be medically experienced personnel with previous intensive care unit or emergency department experience, this survey would suggest that fixed-wing flight programs are variable in the amount of initial training, level of instructors, ongoing medical education, and involvement of the medical director. This survey indicates the need for increased standardization of continuing education, as well as increased involvement of medical directorship in fixed-wing air ambulance services.     

槟榔水提液对胃肠运动的影响

目的：研究槟榔水提液对胃肠运动的作用。方法：采用炭末标记的半固体米糊小鼠胃排空、小肠推进实验以及离体大鼠胃底肌条运动实验，观察槟榔水提液对正常小鼠胃排空、小肠推进、离体大鼠胃底肌条收缩的影响，以及在阿托品或去甲肾上腺素负荷的小鼠胃排空、小肠推进抑制的影响。结果：槟榔水提液1．25g/k、2．5g/k、5g/k对小鼠胃排空有明显加快作用；中、高剂量对小鼠小肠推进也有明显的促进作用。2．5g/k对阿托品或去甲肾上腺素引致小鼠胃排空和小肠推进抑制有拮抗作用。槟榔水提液对大鼠胃底肌条收缩有明显的促进作用，表现为张力基线明显提高，振幅也明显加大。结论：槟榔对胃肠道运动有促进作用。其作用途径除与M胆碱受体有关外，同时很有可能也与α肾上腺素受体有关。