[This retracts the article on p. 209 in vol. 12, PMID: 29628829.].
[This retracts the article on p. 209 in vol. 12, PMID: 29628829.].
Breast cancer surgery often results in significant postoperative pain, which can have psychological, physiological, and socio-economic consequences, and increase the risk of chronic pain. While locoregional anesthesia, including fascial blocks, has become essential in perioperative pain management, achieving adequate coverage in complex breast surgeries, especially with axillary dissection, remains challenging. This report presents a case of a 55-year-old woman undergoing left mastectomy with axillary lymph node dissection. A combination of a unilateral Erector Spinae Plane (ESP) block at the T2-T3 level and a Serratus Posterior Superior Intercostal Plane (SPSIP) block was performed preoperatively. The patient experienced minimal postoperative pain, with low pain scores (0/2) at 3, 12, and 48 hours post-surgery, requiring only one dose of paracetamol. The blocks provided effective analgesia, and the patient had no complications. The combined use of these two fascial blocks enhances coverage by targeting both intercostal and brachial plexus branches, offering a synergistic effect and the proximity of the block sites allows for efficient performance without repositioning the patient, reducing execution time. We believe the synergic combination of SPSIP and ESP blocks offers a promising strategy for pain management in breast cancer surgeries involving axillary dissection.
Background: Robotic-assisted laparoscopic prostatectomy (RALP) poses challenges in ventilation and oxygenation due to steep Trendelenburg positioning and pneumoperitoneum. This study aims to investigate the impact of steep Trendelenburg and pneumoperitoneum on respiratory mechanics, novel oxygenation, and saturation indices.
Methods: Mechanical ventilator, blood gas, and hemodynamic parameters were recorded for 56 RALP patients at three periods (pre-Trendelenburg, Trendelenburg and pneumoperitoneum, post-Trendelenburg). Oxygenation and saturation indices (OIs and OSIs) were calculated and compared using one-way repeated measures ANOVA with Bonferroni post hoc tests.
Results: Elastance, Pplato, Ppeak, Pmean, MPtot, MPdyn, DP, OI-Pmean, OI-MPtot, OI-MPdyn, OI-DP, OSI-Pmean, OSI-MPtot, OSI-MPdyn, and OSI-DP significantly increased with Trendelenburg positioning and pneumoperitoneum. Despite a reduction in the post-Trendelenburg period, these indices remained significantly elevated compared to pre-Trendelenburg levels. Cdyn, Cstat, PaO2, PaO2/FiO2, and PaO2/FiO2*PEEP significantly decreased with Trendelenburg positioning and pneumoperitoneum.
Conclusions: In RALP, pneumoperitoneum and Trendelenburg positioning led to significant increases in respiratory mechanics (Pmean, DP, MP) and oxygenation and saturation indices (OI-Pmean, OI-MPtot, OI-MPdyn, OI-DP, OSI-Pmean, OSI-MPtot, OSI-MPdyn, OSI-DP). These new oxygenation indices may assist clinicians in optimizing the cost-gain balance in perioperative lung-protective ventilation strategies.
Background: Myasthenia gravis (MG) patients undergoing surgery may opt for general anesthesia without neuromuscular blocking agents (NMBAs). The univent tube, featuring a single lumen with bronchial blockers, is known for its flexibility and preference in challenging intubations, reducing airway damage during one-lung ventilation. This study assesses the safety and feasibility of utilizing the univent tube for thoracoscopic thymectomy in MG patients under general anesthesia without NMBAs, complemented by airway topical anesthesia.
Methods: In this single-center, prospective observational study, 83 consecutive MG patients underwent thoracoscopic thymectomy with univent tube intubation. General anesthesia without NMBAs and airway topical anesthesia were administered. Emphasis was placed on intubation conditions, surgical aspects, intraoperative respiratory, and airway complications.
Results: Clinically acceptable intubation conditions were achieved in 99% of patients, with 80% rated as 'excellent' and 19% as 'good.' No cases experienced intubation failure, and 2% exhibited reactions to tracheal tube insertion. Higher MG stages correlated with more favorable intubation conditions, particularly during laryngoscopy. Surgical conditions were excellent in 89%, and blocking the right lung increased total lung collapse, enhancing surgical conditions. Intraoperative ventilation was sufficient for all cases. Incidences of bronchial and vocal cord injuries were 6% and 10%, respectively, with no hematoma cases. Postoperative sore throat (12%) and hoarseness (6%) resolved within three days.
Conclusions: Despite the potential benefits of NMBAs, the univent tube proved safe and effective for thoracoscopic thymectomy in MG patients without NMBAs, with higher MG stages associated with improved intubation conditions and enhanced surgical conditions with right-side bronchial blockage.
Background: Trauma causes a state of hypercoagulability, and its presence is common early in the injury course. D-dimer (DD), considered a good screening tool for coagulation activation and higher plasma levels, has been associated with unfavorable outcomes. Hence, in trauma, measuring DD levels may help provide useful prognostic information. The aim of the study was to find whether DD levels at the time of admission can predict the outcome of patients.
Methods: This prospective observational studied 205 adult patients of age group 18-60 years, presenting to trauma emergency within 24 h of injury and blood samples collected within this period. The primary outcome was to assess whether DD levels at admission predicted outcome. Association of DD levels with injury severity score, with blunt or penetrating trauma, time from injury to admission, and to hospital stay were secondary outcomes. A value of DD >250 ng/ml was considered elevated.
Results: The DD levels were significantly higher in patients who died than those who were discharged [2316.28 (384.5,3331.18) vs 498.03 (140,693), P = 0.001]. On receiver operating characteristic analysis, a cutoff value of 1793.35 ng/ml for serum DD was obtained with sensitivity and specificity values of 72.7% and 60.8%, respectively. The odds of death in patients were 5.87 [95% CI 1.67 to 20.51] times more when DD >1793.35 ng/ml (P = 0.002).
Conclusion: Our study demonstrates that DD levels at admission were high among nonsurvivors compared to survivors. A cutoff value of more than 1793.35 ng/ml is associated with an unfavorable outcome.
Background: Periodontal bone defects pose a significant challenge in stomatology, affecting dental stability and function.
Objective: This study aimed to explore the clinical efficacy of concentrated growth factor (CGF) combined with artificial or autologous bone powder in the treatment of periodontal bone defects.
Methods: A total of 106 patients with bone defects requiring surgical intervention were divided into two groups: the control group and the observation group. Preoperative data were analyzed, and postoperative periodontal indicators, bone resorption markers, and masticatory function were assessed at baseline and 2 weeks, 1 month, 3 months, and 6 months post surgery.
Results: There were no significant differences in baseline characteristics between the two groups. The observation group showed improvements in periodontal probing depth, mucosal recession, plaque index, gingival index, gingival retreat index, and bone gla protein after 6 months. The masticatory function of the observation group was significantly better at 1 to 6 months post operation, and there were significant differences in postoperative pain levels at 6 months.
Conclusion: CGF combined with artificial bone powder demonstrates superior performance in masticatory function recovery and periodontal clinical parameter restoration, indicating potential benefits for periodontal bone defect treatment.
Introduction: Addressing childhood obesity remains a significant public health concern due to the lack of effective intervention programs and policies. While efforts are ongoing to evaluate perioperative complications related to childhood obesity, there has been limited exploration of parents' and caregivers' knowledge and attitudes toward the perioperative risks associated with their children's obesity. This prospective survey evaluated parents' beliefs and practices related to childhood obesity and determined if these influenced their knowledge of obesity-related perioperative complications.
Methods: We performed a prospective survey of parents of children aged 2-17 years scheduled for elective operations at a US quaternary academic medical center. The survey instrument was pretested. The frequency of obesity-related perceptions, beliefs, and practices were assessed, stratified by child weight status. Group comparisons were made with appropriate statistical tests.
Results: The study included 129 parents, of whom 87 (67.4%) were married, and 102 (79.1%) were women. Most parents, regardless of perceived child weight, agreed that child overweight/obesity can cause serious illness (95%) and that they should be concerned (90%). Notably, 40% of parents failed to recognize obesity in their own children. About 40% of parents were unsure about the impact of childhood obesity on postoperative pain control, and 29% were uncertain about its effect on anesthesia risks. Additionally, 20% of parents were uncertain about the potential for serious surgical complications related to obesity, and 5% believed that being overweight or obese does not lead to significant surgical risks.
Conclusions: While awareness of child overweight/obesity as a modifiable health risk is high, many parents failed to recognize it in their own children and were unaware of its potential contribution to anesthesia-related complications. Additional efforts to help parents understand their role in facilitating behavior change and to assist them in identifying at-risk children as well as the perioperative implications of childhood obesity are required.
Reports on intraoperative coagulation monitoring using viscoelastic testing methods are scarce in oncosurgical patients. Evidence-based clinical reports with the use of Sonoclot and subsequent corrections of coagulation abnormalities in above population are not available in the literature. We report here records of altered coagulation in 10 subjects with massive hemorrhage. Detection of intraoperative coagulation abnormalities was done using activated clotting time, clot rate, and platelet function. The most common Sonoclot signature abnormality found in our series was a poorly formed, dull, and rounded "peak," indicative of irregularities of fibrin formation. Dilutional coagulopathy and hyper-fibrinolysis events too were recorded in few subjects. Appropriate transfusions with blood products were considered based on Sonoclot curve assessment. All subjects had adequate recovery. We conclude that the Sonoclot analysis demonstrates potential for optimizing blood product use in oncosurgical patients with massive hemorrhage, warranting further research to establish standardized protocols and quantify its impact.
Medication errors carry the potential for serious patient harm and even death. Prescription and medication administration errors are common, while the incidence of dispensing errors is less consistent due to difficulties in detection and under-reporting. This case report describes an incident in which a busy pharmacy in a quaternary care hospital dispensed a norepinephrine infusion that actually contained epinephrine. The error became apparent only after the patient, undergoing living donor liver transplantation surgery, developed unexpected, dramatic, and potentially fatal instability, which worsened with progressively higher doses of norepinephrine. The differentials of the presentation were sequentially excluded, leading to the realisation that the contents of the dispensed medicine might have been inaccurate. When a freshly prepared infusion of norepinephrine replaced the pharmacy-supplied bag, the adverse parameters reversed, and the patient stabilised. This case underscores the importance of maintaining a high index of suspicion for medication dispensing errors, as doing so helped identify the cause and ultimately saved the patient's life.
There is an emerging body of evidence to suggest that the peripheral administration of vasopressors is safe and effective in many clinical contexts and often superior to central administration. Vasopressors are a class of medications used to create vasoconstriction in patients with shock to increase systemic arterial blood pressure and tissue perfusion. Certain clinical circumstances require the use of these vasoactive drugs immediately for which the need to administer these drugs peripherally becomes paramount, although controversial. The authors present a narrative review dedicated to describing the current practice of the route of administration of vasopressors, comparing peripheral versus central administration, and explaining the advantages and drawbacks of each route as well as potential complications associated with them.
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