Anesthetic considerations for endo-vascular management of intracranial aneurysms

Intra cranial aneurysms are acquired lesions responsible for about 80% of non-traumatic sub arachnoid hemorrhage. Treatment of the condition in the past has relied on craniotomy and clipping of the aneurysm to prevent a recurrent hemorrhage. Nowadays endovascular coiling is the best primary treatment. The anesthesia in interventional radiology room has special arrangement and precautions. Intra operative management of endovascular cerebral aneurysm from the start including: arrangement of the room, monitoring, induction, maintenance and emergence of the patients. Post-operative care is very important and good management of potential perioperative complications like: aneurysm rupture, cerebral infarction, cerebral vasospasm, contrast reaction and nephropathy is mandatory

Aim of the Study: reviewing the current medical literature as regards the anesthetic considerations and problems of endo-vascular management of intracranial aneurysm

Conclusion: anesthesia in interventional radiology room should have special arrangements and precautions. Intra operative management of endovascular cerebral aneurysm from the start including: arrangement of the room, monitoring, induction, maintenance and emergence of the patients. Post-operative care plays a key role in mitigating potential perioperative complications like: aneurysm rupture, cerebral infarction, cerebral vasospasm, contrast reaction and nephropathy are mandatory

Roux-en-Y hepaticojejunostomy versus hepaticodudenostmy for biliary reconstruction after excision of choledochal cysts in children

Primary cyst excision combined with biliary reconstruction is the standard treatment of choledochal cysts. Roux-eu-Y hepatico-jejunostomy [RYHJ] or hepatico-duodenostomy [HD] is the most commonly used techniques for biliary reconstruction. This study was undertaken to compare the operative details and postoperative functional results of patients treated with either RYHJ or HD on both early and long term follow up. This retrospective study included 27 patients with choledochal cysts, who were treated during the period from 1993 to 2005. Complete excision of the extra-hepatic cysts was done in all patients. The study population was classified into two groups according to the method used for biliary reconstruction. Group 1 included 18 patients who undergone RYHJ, while group 2 included 9 patients treated with HD. All patients were studied as regard to the details of clinical presentation, diagnostic tools, operative details, and outcome. Statistical comparison was done with unpaired t and x[2] tests, with P value less than 0.05 considered significant. The age and sex distributions were comparable among both groups. The mean operative time was longer in group 1 than in group 2 [160.4 versus 131.1 minutes, P =0.003]. Intraoperative blood transfusion was not required in any patient. The start of oral postoperative feeding was similar in both groups [2.6 versus 2.1 days]. The hospital stay was comparable in both groups [5.1 versus 4.8 days]. There were no major intraoperative complications in either group. Postoperative cholangitis occurred in 4 patients [2 in each group]. Adhesive bowel obstruction occurred in 2 children in group I [treated successfully by conservative management]. One late mortality due to liver failure occurred 6 months after RYHJ with preoperative severe liver cirrhosis. Total excision of choledochal cyst is usually feasible. Both RYHJ and HD are effective techniques for biliary reconstruction following excision of the cyst with satisfactory and comparable results on both early and long-term follow up. Hepatico-duodenostomy may be preferred due to shorter operative time and avoidance of intestinal anastomosis; however more patients with HD are required before reaching a solid conclusion

Neutrophil-surface antigens CD11b and CD64 expression: a potential predictor of early-onset neonatal sepsis

Background: CD11b, an alpha subunit of the beta2 integrin adhesion molecule, and CD64, the high affinity Fc-gamma receptor I, are specific neutrophil-surface antigens activated in response to systemic inflammation and, hence, they might potentially help identifying neonatal infections

Objective: We sought to evaluate the time course of expression and diagnostic and prognostic utility of CD11b and CD64 in early-onset sepsis in the suspected newborn

Methods: Sixty newborn infants [28-40 weeks gestation] with antenatal risk factors for sepsis were enrolled and subjected to sepsis work-up including complete blood count, quantification of serum C reactive protein [CRP] and flow cytometric analysis of CD11b and CD64 in cord blood [0 h]. These tests were repeated at 8, 24 and 48 h postnatally. Neonates were defined, retrospectively, in two groups: sepsis and no infection, on basis of clinical observation over their first five postnatal days and sepsis work-up results

Results: A significant enhancement of neutrophil CD11b and CD64 expression was demonstrated in the sepsis group as compared to the non-infected group. CD11b over-expression had an onset at 0 h. Its mean value approached two-fold mean level of non-infected neonates by 8-24 h, and declined thereafter. CD64 rising onset was detectable at 8 h and its mean percentage reached four-fold mean value of the non-infected group at 24 h. At 24 h, an optimal cut-off value for CD11b expression of 35% [sensitivity 80%, and specificity 100%], and for CD64 expression of 17% [sensitivity 88%, and specificity 90.3%] had the best performance for prediction of sepsis. Combined use of both markers at 24 h yielded 90% sensitivity and 95% specificity for sepsis prediction. Sepsis survivors showed significantly lower mean expression for CD11b and CD64 as compared to those with fatal outcome. At 24 h, a cut-off value of 88% expression for CD11b and 50% expression for CD64 predicted mortality with sensitivity and specificity of 100%

Conclusion: Enhanced expression of neutrophil-surface antigens CD11b and CD64 could be a promising tool for prediction and therapeutic decision-making in early-onset sepsis indicating the necessity of initiation of antimicrobial therapy and reduction of its unnecessary use in non-infected neonates even before definitive microbiologic identification

importance of pathological findings in identification of patients at risk of developing Hirschsprung's disease associated enterocolitis

Enterocolitis remains the most serious complication of Hirschsprung's disease, and has been reported in 15% to 50% of cases. Patients are prone to develop relapses despite a defunctioning colostomy and after definitive pull-through procedures. There are several risk factors as delayed diagnosis of Hirschsprung's disease, long spastic segment, trisomy 21 and .family history of Hirschsprung's disease. Currently no clinical factor or test is available to predict patients prone to develop postoperative enterocolitis. Thirty-two Hirschsprung's disease patients were studied in an attempt to correlate the histologic changes of the colonic mucosa with the clinical and post-operative course to outline a histological guide line of value in prediction of patients prone to develop clinical enterocolitis

One-stage swenson pull-through surgery for the treatment of Hirschsprung's disease in the neonatal period

In 1948 Swenson and Bill described the first reconstructive Operation to treat Hirschsprung's disease. Classically, the definitive pull through was' postponed until the patient was around the age of 8 to 12 months. Neonates were decompressed after diagnosis with either a defunctioning colostomy or by regular rectal irrigation, Interest in neonatal one .stage reconstruction for Hirschsprung's disease has been increasing steadily because of the obvious clinical quality issues and resource benefits, Over a period of three years twenty- eight cases of biopsy proven Hirschsprung's disease were treated by a one stage Swenson's repair before their first month of life. Twenty-two males and six females with an age ranging from 3 to 27 days were included in this study. Their weight ranged from 3.5 to 4.8 kg. These neonates were followed up for a mean of 9. 5 months [range 6 months to 2 years], Postoperatively most patients had regular bowel habits, only 3 out of28 complained from .soiling in excess of once per week. There was no mortality in the series, with complication rate [anastomotic leakage [n = 1], adhesive intestinal obstruction [n = 1], postoperative enterocolitis [n = 2] and anastomotic stricture [n = 2]] comparable to other lines of therapy. Neonatal primary repair represents a .safe and effective method of managing Hirschsprung's disease with the patients benefiting from having no stoma, and a shorter hospital stay

Non-operative treatment for blunt liver trauma in children: a successful, safe, cost effective protocol

In this study, a protocol for managing hepatic trauma in hemodynamically stable children was proposed where specific criteria for pediatric ICU admission were applied and ultrasonography replaced CT scan for following up the process of hepatic healing. The study was carried out on 51 children with blunt hepatic trauma. Initial CT scan was done to 49 patients and identified the hepatic injuries and their grade in all patients. Intraperitoneal fluid was found in 26 of these patients. CT scan at discharge confined the ultrasound findings in 47 discharge patients. Four patients died, one due to grade VI liver injuries and the other three due to severe associated head injuries. Although the pediatric ICU was the standard location for initial nonoperative management of children with blunt hepatic injuries, yet a successful, safe and cost effective treatment could be achieved for properly selected hemodynamically stable patients. Ultrasonography was an effective alternative to CT for following up the healing process of these liver injuries