Ario Santini, Leonard Azamfirei and Cosmin Moldovan
Zoltán Ruszkai, Erika Kiss and Zsolt Molnár
Lung protective mechanical ventilation (LPV) even in patients with healthy lungs is associated with a lower incidence of postoperative pulmonary complications (PPC). The pathophysiology of ventilator-induced lung injury and the risk factors of PPCs have been widely identified, and a perioperative lung protective concept has been elaborated. Despite the well-known advantages, results of recent studies indicated that intraoperative LPV is still not widely implemented in current anaesthesia practice.
No nationwide surveys regarding perioperative pulmonary protective management have been carried out previously in Hungary. This study aimed to evaluate the routine anaesthetic care and adherence to the LPV concept of Hungarian anaesthesiologists during major abdominal surgery.
A questionnaire of 36 questions was prepared, and anaesthesiologists were invited by an e-mail and a newsletter to participate in an online survey between January 1st to March 31st, 2018.
A total of one hundred and eleven anaesthesiologists participated in the survey; 61 (54.9%), applied low tidal volumes, 30 (27%) applied the entire LPV concept, and only 6 (5.4%) regularly applied alveolar recruitment manoeuvres (ARM). Application of low plateau and driving pressures were 40.5%. Authoritatively written protocols were not available resulting in markedly different perioperative pulmonary management. According to respondents, the most critical risk factors of PPCs are chronic obstructive pulmonary diseases (103; 92.8%); in contrast malnutrition, anaemia or prolonged use of nasogastric tube were considered negligible risk factors. Positive end-expiratory pressure (PEEP) and regular ARM are usually ignored. Based on the survey, more attention should be given to the use of LPV.
Bhavna P Singh, Gurucharan S Shetty, Padmakumar Arayamparambil Vijayan, Ullas Gopalakrishna, Garud Chandan, Ario Santini and Vivek Padegal
H1N1 is seen in tropical countries like India, occurring irrespective of the season. Complications of the disease are frequently encountered and there is little in the way or guidelines as to the how these should be managed. The treatment of one such complication, a recurrent pneumiomediastinum is the subject of the current paper. The management followed guidance for the treatment of a similar condition known as primary spontaneous pneumomediastinum, an uncommon condition resulting from alveolar rupture-otherwise known as the Macklin phenomenon.
Tatiana Daniela Sala, Simona Mureşan, Ramona Roman, Alexandra Lazăr, Răzvan Ion and Ionela Paşcanu
A hypercalcaemic crisis, also called para thyrotoxicosis, hyper parathyroid crisis or parathyroid storm, is a complication of primary hyperparathyroidism (PHPT) and an endocrinology emergency that can have dramatic or even fatal consequences if it is not recognised and treated in time.
Two cases presented in the emergency department with critical hypercalcaemic symptoms and severe elevation of serum calcium and parathyroid hormone levels, consistent with a hypercalcaemic crisis. The first case, a 16-year-old female patient, had imaging data that highlighted a single right inferior parathyroid adenoma and a targeted surgical approach was used. The second case, a 35-year-old man was admitted for abdominal pain, poor appetite, nausea and vomiting. Laboratory tests revealed severe hypercalcaemia, hypophosphatemia and an increased serum iPth level. There was no correlation between scintigraphy and ultrasonography, and a bilateral exploration of the neck was preferred, resulting in the exposure of two parathyroid adenomas. The patients were referred for surgery and recovery in both cases was uneventful
These cases support the evidence that surgery remains the best approach for patients with a hypercalcaemic crisis of hyperparathyroidism origin, ensuring the rapid improvement of both the symptomatology and biochemical alterations of this critical disease.
Piero Portincasa, Emilio Molina-Molina, Gabriella Garruti and David Q.-H. Wang
Approximately twenty per cent of adults have gallstones making it one of the most prevalent gastrointestinal diseases in Western countries. About twenty per cent of gallstone patients requires medical, endoscopic, or surgical therapies such as cholecystectomy due to the onset of gallstone-related symptoms or gallstone-related complications. Thus, patients with symptomatic, uncomplicated or complicated gallstones, regardless of the type of stones, represent one of the largest patient categories admitted to European hospitals.
This review deals with the important critical care aspects associated with a gallstone-related disease.
Peter Biro and Martin Schlaepfer
Study objective. Videolaryngoscopes can be fitted either with channeled or non-channeled blades, which may result in a different performance and success of tracheal intubation. We investigated the characteristics of the two different blade types of the commercially available KingVisionTMvideolaryngoscope. Design. A prospective, randomized, single center investigation study in a urological operation unit of a tertiary hospital. Subjects and Methods. Forty adult patients undergoing elective urological surgery in general anaesthesia with tracheal intubation were randomly allocated into group 1 (channeled videolaryngoscopy, n = 20) and group 2 (non-channeled videolaryngoscopy, n = 20). We measured the times from laryngoscope insertion to recognize the glottis and to conclude tracheal intubation. The number of laryngoscopy/intubation attempts and the degree of visual glottis exposure on a visual analog scale from 0 (glottis not visible) to 10 (glottis fully visible) was assessed. The lowest SpO2value during airway management was recorded. Results. There was no statistically significant difference in biometric data between the 2 groups. The time from the laryngoscope insertion to glottis recognition with the non-channeled blades was 5 (4-8) s as compared to the channeled ones with 11 (7-14) s (median and range; p = 0.01). Intubation duration was shorter with the channeled blades 17 (12-27) s vs. 29 (25-51) s (median and range; p < 0.001). Number of laryngoscopy/intubation attempts, grades for glottis visibility, intubation difficulty were not different. The lowest SpO2was 98% in both groups. Conclusions. Videolaryngoscopic glottis recognition time was longer and the total time to secure the airway was shorter with the channeled blades.
Mihai Popescu, Dana Tomescu and Simona Olimpia Dima
Early allograft dysfunction (EAD) represents one of the most common and serious complications after liver transplantation (LT). Methods. One hundred sixty-four patients who underwent LT were prospectively included in the present study. Patient demographics, intraoperative blood loss and transfusion were recorded at the time of LT. Lactate levels were recorded during surgery and daily for the first 3 postoperative days. Standard and derived rotational thromboelastometry (ROTEM) parameters were recorded 24 hours after LT. EAD was diagnosed according to Nanashima criteria and post anaesthesia care unit length of stay was recorded. Results. Forty-seven patients (28.6%) developed EAD. Intraoperative blood loss (p = 0.01), packed red blood cells (p = 0.04) and fresh frozen plasma (p = 0.01) transfusion represented intraoperative risk factors for EAD. Lactate levels were significantly higher in patients with EAD at all time points. Patients with EAD demonstrated an increased clot formation time and decreased maximum clot firmness in both intrinsically (p < 0.01) and extrinsically (p < 0.01) activated assay, a decreased thrombin potential index (p < 0.01), area under the curve (p < 0.01) and clot elasticity (p < 0.01) on ROTEM assay. Conclusion. Our results show that both standard and derived ROTEM parameters may indicate early signs of graft failure and can aid in the diagnosis of EAD.
Alexander M. Ioscovich, Oksana V. Riazanova and Yurii S. Alexandrovich
Postpartum depression (PPD) is the main psychological status disorder and women suffering from postpartum depression often need long-term psychological and socio-economic rehabilitation. The study is dedicated to the evaluation of the role of labor pain management using epidural analgesia in natural delivery on stress level in labor and frequency of postnatal depression. Materials and methods: 210 women were investigated and divided into two groups. In the first group for labor pain management in natural delivery, patient-controlled epidural analgesia was used (bolus - 10.0 - 0.08% ropivacaine hydrochloride, lockout - 30 min, limit - 120 ml/6 h) with a background of continuousflow infusion of local anesthetic 0.08% ropivacaine hydrocluoride solution. Patients in the second group had no pain relief in delivery. The stress level was evaluated using blood plasma cortisol level in the early stages of labor, 6 hours and 3 days after delivery. The assessment of depression development was carried out step-by-step: Before the delivery, 6 hours after, 3 days and 6 weeks after the delivery. Results: The baby blues frequency 6 hours after the delivery in the group where the pain relief was conducted was 29.91%, with cortisol level below and equal to 2310.91 nmol/l. In the group with no pain relief 6 hours after delivery, baby blues was found in 15.53% of puerperas (p < 0.05) and the cortisol level was 2673.82 nmol/l (p < 0.05). Six weeks after the birth, postpartum depression was diagnosed in 4.67% of women who received epidural analgesia during delivery, in comparison to 6.79% with no pain relief during delivery. However, the difference was not statistically significant (p < 0.05). Conclusions: The use of epidural analgesia leads to a significant reduction of pain syndrome and stress response during natural delivery, increases the risk of baby blues in the early postnatal period, but slightly influences the frequency of postpartum depression.
Arun Kalava and Abby M. Pribish
Background and Aims. Atrial fibrillation (AF) is the most common arrhythmia seen clinically. Due to the lack of literature and guidelines on maternal AF as a postoperative complication following cesarean delivery (CD), we undertook a study to characterize parturients who developed AF following CD and to evaluate arrhythmia management and outcomes in this patient population. Methods. After receiving ethics committee approval, a retrospective chart review was performed to determine the incidence, possible risk factors, treatment, and outcome of women who developed AF following CD performed between 2003 and 2012 at New York Methodist Hospital in Brooklyn, New York. Results. A total of 17,039 CDs were performed at New York Methodist Hospital from 2003 to 2012. Of these, seven parturients developed AF after CD. The incidence of AF following CD in this patient population was 1:2,434 (0.04%). The age range was 26-41 years, with a median of 33 years. All 7 parturients were at term or postterm. Two deliveries were elective and five were emergent. Two of the seven parturients had prior history of paroxysmal AF. One patient was identified as having mitral regurgitation. All seven had low levels of serum magnesium postoperatively. Out of the seven, two parturients had spontaneous conversion to normal sinus rhythm, one required electrical cardioversion and four required pharmacologic cardioversion. Conclusions. Postoperative AF (POAF) exists as a rare complication in women who undergo CD with an incidence of 0.04% in our patient population. All parturients in our study were noted to have hypomagnesemia in the postoperative period. Occurrence of AF increased length of hospital stay and utilization of hospital resources.