A comparison of 3% hypertonic saline and mannitol for brain relaxation during elective supratentorial brain tumor surgery.

BACKGROUND: In this study, we compared the effects of 3% hypertonic saline (HTS) and 20% mannitol on brain relaxation during supratentorial brain tumor surgery, intensive care unit (ICU) stays, and hospital days. METHODS: This prospective, randomized, and double-blind study included patients who were selected for elective craniotomy for supratentorial brain tumors. Patients received either 160 mL of 3% HTS (HTS group, n = 122) or 150 mL of 20% mannitol infusion (M group, n = 116) for 5 minutes at the start of scalp incision. The PCO(2) in arterial blood was maintained within 35 to 40 mm Hg, arterial blood pressure was controlled within baseline values +/-20%, and positive fluid balance was maintained intraoperatively at a rate of 2 mL/kg/h. Outcome measures included fluid input, urine output, arterial blood gases, serum sodium concentration, ICU stays, and hospital days. Surgeons assessed the condition of the brain as "tight," "adequate," or "soft" immediately after opening the dura. RESULTS: Brain relaxation conditions in the HTS group (soft/adequate/tight, n = 58/43/21) were better than those observed in the M group (soft/adequate/tight, n = 39/42/35; P = 0.02). The levels of serum sodium were higher in the HTS group compared with the M group over time (P < 0.001). The average urine output in the M group (707 mL) was higher than it was in the HTS group (596 mL) (P < 0.001). There were no significant differences in fluid input, ICU stays, and hospital days between the 2 groups. CONCLUSIONS: Our results suggest that HTS provided better brain relaxation than did mannitol during elective supratentorial brain tumor surgery, whereas it did not affect ICU stays or hospital days.

Pneumomediastinum complicated by subclavian central venous catheterization in a severe thoracic trauma patient.

Pneumomediastinum is a rare event in subclavian central venous catheterization. However in severe thoracotraumatized patients, such as with bilateral hemopneumothorax, the catherization may be hazardous and made complex by occurrence pneumomediastinum, even the procedure is rightly carried out. We suggest that in such a risky condition, if it is mandatory, it should be carried out in a more placid condition, such as avoidance of high PEEP ventilation, setting lower tidal volume, or brief interruption of positive ventilation, to reduce the likelihood of unperceivable pneumomediastinum.

Repeated lumbar sympathetic blockade with lidocaine and clonidine attenuates pain in complex regional pain syndrome type 1 patients--a report of two cases.

Repeated lumbar sympathetic blockade (LSB) with local anesthetics is generally used in complex regional pain syndrome (CRPS) of the lower extremities if the initial block has been successful. However, the symptoms of CRPS may inevitably recur in spite of repeated LSB. Clonidine, an alpha2-adrenoceptor agonist, has both anesthetic and analgesic sparing effects, and when added to local anesthetics may enhance peripheral and central neural block due to its local or central analgesic effects. It is reasonable that clonidine has been used in chronic pain conditions such as neuropathic and sympathetically maintained pain. Here we report two cases of CRPS type 1 who got excellent analgesia and alleviation of clinical symptoms after receiving an LSB with lidocaine and clonidine.

Acute airway obstruction associated with granulation tissue of tracheostoma--a case report.

We report an 85-year-old tracheostomized male patient who underwent ventriculoperitoneal shunt because of hydrocephalus. Postoperative acute airway obstruction and tension pneumothorax developed due to the granulation tissue of tracheostoma which scraped off from the tracheostoma in the act of endotracheal intubation for operation and it lay dormant around until it was drawn into the endotracheal tube (ETT) by negative pressure during suction of trachea in intensive care unit. Persistent hypoxemia in consequence of airway obstruction resulted in cardiac arrest and expiratory seal of trachea eventuated in tension pneumothorax. Flexible fiberoptic bronchoscopy performed during resuscitation disclosed that the obstruction was due to granulation tissue which blocked the ETT lumen. Immediate exchange of endotracheal tube and placement of chest tube made the patient tide over this crisis. No sequela resulted from this crisis and the patient was discharged one week later.