Renewing of Ravitch approach for repair of pectus excavatum deformity: Surgical and anesthetic implications

Pectus excavatum is the most common chest wall deformity referred for surgical correction. As a congenital lesion, it is a highly visible anomaly and is easily diagnosed. Its anatomic severity can be readily assessed by visual measurement. Repair is undertaken to alleviate symptoms of pain, cardiac or respiratory compromise, as well as to diminish significant psychosocial consequences to a child or adolescent. Was to study results of renewing the standard surgical approach to the pectus repair based on the technique described by Ravitch. Several technical modifications in the operative procedure and perioperative management strategy were added. Two post-operative pain management techniques were used following the Ravitch repair of pectus excavatum: continuous intravenous opioid analgesia, and thoracic epidural analgesia using opioid and local anesthetic combination. This study included 15 patients [nine females 60% and six males 40%], their ages ranged from 8-13 years old with a mean of 10.6 +/- 2.7 subjected to pectus excavatum repair in the cardio-thoracic surgery department between 2001 and 2006. A limited transverse submamary skin incision with generous subcutaneous flap over the muscle fascia. Three to four sets of costal cartilages were removed to get optimal remodeling. The xiphoid process was detached from the sternum. An anterior wedge osteotomy was done using the redo sternal saw leaving the posterior table intact. Final stabilization was done using Kirshner wires mounted on drill, passing transversely under the lower segment of the sternum. Asymmetry can be easily dealt with by adjusting the angle of the osteotomy. Thoracic epidural catheter was routinely placed preoperatively by the anesthesiologist at the most appropriate level between T3 and T8, after induction of general anesthesia. No operative mortality or significant infra-operative morbidities were reported. Blood loss was minimal. Two children developed ileus. One patient had a wound infection that required incision and drainage. Seromas developed after discharge in two patients. All patients had extubated before leaving the operating room and were sent to the thoracic surgery ward after leaving the recovery room. Both regimens provided effective analgesia. A low morbidity with excellent short- and long-term results combined with a high level of patient satisfaction were achieved and should be the standard against which the Nuss procedure is compared. Indwelling epidural catheters placed at the time of surgery lead to smooth postoperative course. This strategy has greatly reduced the amount of narcotics required and allowed for more rapid mobilization

Evaluation of head injured patients: comparison of clinical, CT scanning and neurobiochemical markers as predictors of outcome

To investigate the predictive value of the initial serum level of NSE and S-100B compared with the GCS score and cranial CT scan in the prediction of outcome in cases of head injury. Thirty patients with different grades of traumatic head injury were enrolled in this study after taking an informed consent. Data obtained on admission included age, sex and GCS. In addition, cranial CT was done and serum samples were taken from each patient for determination of NSE and S-100B levels. GOS was obtained at the time of patients' discharge. The mean age of head injured patients was 26.70 +/- 10.96 years. Males constituted 66.7% of the cases. It was found that initial GCS score was significantly correlated with GOS with a sensitivity of 85.71%, a specificity of 95.65% and overall accuracy of 93.33%. A significant correlation was also found between CT findings and GOS and the predictive value of CT findings was found to be of 100% sensitivity, specificity and overall accuracy. Post-traumatic serum concentrations of S-100B and NSE were found to be significantly higher in patients with poor outcome compared to those with good outcome, and a significant negative correlation was found between these levels and the GOS. The overall accuracy for the S-100B and NSE were 90.0% and 96.67%, respectively. Clinical interpretation of outcome in traumatic head injury is not a reliable method. CT scanning and neurobiochemical markers, especially NSE, are better predictors

value of intraperitoneal meperidine for amalgesia after laparoscopic cholecystectomy

Postoperative pain has been an important limiting factor for ambulatory laparoscopic chlecystectomy. The intraperitoneal [IP] administration of drugs is controversial but has proven effective in some studies for the relief of postoperative pain following laparoscopic surgery. However, some investigators have not been able to confirm the analgesic efficacy of IP local anaesthetics. The administration of IP opioids for the relief of postoperative pain has received little attention. Forty patients, ASA physical status I and II were scheduled for laparoscopic cholecystectomy. At the end of anaesthesia, the patients were randomized into one of two groups: Patients of group A received 20 ml of IP ropivacaine 0.75% [150mg] and 50 mg of IM meperidine. Patients of group B received 20 ml of IP ropivacaine 0.75% [150mg] and 50 mg of IP meperidine. Postoperative pain scores were measured at rest and with movement at certain time periods for the first 24 hours. Pain scores were significantly lower in the group receiving the IP meperidine both at rest and with movement especially during the early post- operative hours. It was concluded that the combination of IP ropivacaine and IP meperidine was better than the combination of IP ropivacaine and IM meperidine for postoperative analgesia in patients undergoing laparoscopic cholecystectomy

Short term effects of prone position in mechanically ventilated patients with acute respiratory failure

A major goal in treating patients with acute respiratory failure [ARF] is to provide adequate delivery of oxygen. Current supportive therapies, including mechanical ventilation, positive end expiratory pressure [PEEP] and administration of high concentrations of oxygen. often entail a substantial risk to these patients. Several studies have revealed that improvement in oxygenation can be achieved by placing patients in the prone position. The aim of this study was to evaluate the short term effects of prone position on oxygenation and lung mechanics in patients with ARF requiring mechanical ventilation, The present study was conducted, on 30 patients with ARF admitted to the Critical care Medicine Department of Alexandria Main university Hospital. They were differentiated into 3 groups namely: ARDS group. COPD+ARDS group and COPD+ ACRF group All patients tolerated turning from supine to prone position rcmarkahjyremarkably well. There were significant increase in arterial oxygen tension [PaO2] when patients were turned prone. This improvement of PaO2 remained so until the patients were returned supine again. There was no significant retduction of the arterial carbon dioxide tension [PaCo2] throughout the study except when the patient were returned supine. A constant improvement in arterial oxygen saturation [SaO2] was observed throughout the study. The hypoxemic index [PaCO2/FiO2] improved significantly with prone positnnung and remained so in some patients [n=16] when they were returned supine. Twenty four patients were responders [achieved <20 mmHg increase of PaO2/FiO2] while, the other 6 patients were nan responders [achieved 20 mmHg increase of PaO2/FiO2]. Peak inspiratory pressure [P. I. P.] and plateau pressure [Ppl] were reduced significantly throughout the study. Dynamic lung compliance and static compliance showed significant increases throughout the study. Airway resistance as well as auto PEEP were reduced significantly. Prone positioning is a simple and safe procedure to improve oxygenation and lung mechanics in many critically ill patients with ARl, allowing for reduction of FiO2 and/or PEEP

Intentional [tourniquet] ischaemia and the role of propofol as an antioxidant in the attenuation of reperfusion injury

Reactive oxygen species which damage cellular components and initiate the lipid peroxidation process are known to be responsible for the ischaemia-reperfusion injury. Lipid peroxidation is a chain reaction leading to oxidation of polyunsaturated fatty acids which, in turn, disrupts the structure of biological membranes and produces toxic metabolites such as malondialdehyde [MDA]. The use of pneumatic tourniquet for bloodless limb surgerv is accepted as a good human model for the study of ischaemiareperfusion injury. Propofol [2,6 diisopropylphenol] is chemically similar to phenol based free radical scavengers. It has been shown to exhibit significant antioxidant activity. This study was carried out to study the role of propofol as an antioxidant, in the attenuation of ischaemia -reperfusion injury induced by the use of pneumatic tourniquet in lower limb surgery. Thirty adult ASA III patients scheduled for lower limb surgery were studied. Patients were randomly allocated into two equal groups. In the propofol group, anaesthesia was induced using fentanyl and propofol followed by a continuous infusion of propfol adjusted according to clinical signs and anticipated demands. In the control group, anaesthesia was induced using fentanyl and thiopentone. Inhalational maintenance was then carried out with 1-2% isoflurane in oxygen. In both groups, a pneumatic tourniquet was then applied on the limb to be operated upon. Parameters studied included: heart rate, arterial blood pressure, ECG, arterial blood gases, serum potassium level, serum malondialdehyde [MDA] level, serum level of reduced glutathione [GSH], and superoxide dismutase [SOD] enzyme activity in the RBCs. In both groups tourniquet deflation was accompanied by a significant increase in heart rate, a significant decrease in arterial blood pressure, significant decrease in arterial blood pH, and a significant increase in serum potassium. In the propofol group, following tourniquet deflation, there were no significant changes in serum MDA level, serum GSH level, and SOD enzyme activity. In the control group, there was significant increase in serum MDA level, significant decrease in serum G.S.H level, and significant inhibition in SOD enzyme activity. In conclusion, propofol attenuated ischaemia-reperfusion -induced lipid peroxidation in therapeutic doses used in anaesthesia. Also, it delayed the exhaustion of naturally occurring antioxidants