Early postoperative seizures after vocal fold surgery attributed to shigellosis.

A 44-year-old previously healthy woman underwent surgery of the vocal folds and developed early postoperative seizures caused by an unusual aetiology. Clinical assessment and laboratory results revealed that the patient suffered from an acute-onset shigellosis infection which was thought to be the cause of her early postoperative seizures. The shigellosis infection was treated with azithromycin which resulted in rapid clinical improvement, and the seizures were successfully managed with benzodiazepines, sodium valproate and levetiracetam. To our knowledge, this is the first reported case of shigellosis-induced seizures in an adult in the peri-operative period. Early detection of the aetiology of seizures is crucial to ensure appropriate management and a safe patient outcome.

Pre-selection of primary intubation technique is associated with a low incidence of difficult intubation in patients with a BMI of 35 kg/m2 or higher.

BACKGROUND: The incidence of difficult intubation (DI) in obese patients may reach a two-digit figure. No studies have assessed the effect of primary use of special intubation devices on lowering the incidence of DI. We assessed the effect of primary selection of special intubation techniques on the incidence of DI in patients with a BMI of 35 kg/m2 or higher. PATIENTS AND METHODS: Data from 546 patients with a BMI of 35 kg/m2 or higher who underwent bariatric surgery at Wolfson Medical Center from 2010 through 2014 was retrospectively extracted and analyzed for demographics, predictors of DI and intubation techniques employed. Difficult intubation was defined as the presence of at least one of the followings: laryngoscopy grade 3 or 4, need for >1 laryngoscopy or intubation attempt, need for changing the blade size, failed direct laryngoscopy (DL), difficult or failed videolaryngoscopy (VL-Glidescope), difficult or failed awake fiberoptic intubation (AFOI) and using VL or awake AFOI as rescue airway techniques. Primary intubation techniques were direct DL, VL and AFOI. We correlated the predictors of DI with the actual incidence of DI and with the choice of intubation technique employed. RESULTS: The overall incidence of DI was 1.6% (1.5% with DL vs. 2.2 with VL + AFOI, p = 0.61). With logistic regression analysis, age was the only significant predictor of DI. Predictors of DI that affected the selection of VL or AFOI as primary intubation tools were Mallampati class 3 or 4, limited neck movement, age, male gender, body mass index and obstructive sleep apnea syndrome. CONCLUSION: The lower incidence of DI in our study group may stem from the primary use of special intubation devices, based on the presence of predictors of DI.

Effect of general anesthesia and intubation on parathyroid levels in normal patients and those with hyperparathyroidism.

BACKGROUND: Induction of general anesthesia and endotracheal intubation may precipitate parathyroid hormone (PTH) elevation in patients with primary hyperparathyroidism (HPT). The purposes of this study were to revisit this observation and to study its impact in healthy patients. METHODS: Patients with primary HPT who underwent parathyroidectomy were retrospectively studied. The PTH was sampled and compared: before, immediately after general anesthesia and endotracheal intubation, and 15 minutes after parathyroidectomy. Healthy adults who underwent elective operations were prospectively studied. The PTH was sampled before general anesthesia and endotracheal intubation, immediately after, and 15 minutes later. RESULTS: Thirty-one patients, aged 28-89 years (mean 60.1 ± 13 years), were retrospectively studied. The PTH was significantly elevated after general anesthesia and endotracheal intubation (P = .014). Fifty patients, aged 21-86 years (mean 54 ± 15 years), were prospectively studied. The PTH elevation after general anesthesia and endotracheal intubation was not significant. CONCLUSION: General anesthesia and endotracheal intubation causes an immediate, steep, and significant PTH elevation in patients with primary HPT but only a minor change in healthy adults. The difference may be attributed to an impaired adrenergic response in patients with primary HPT.

Does meperidine analgesia affect the incidence of obstetric lacerations at vaginal delivery?

PURPOSE: To study whether meperidine analgesia affects the incidence of obstetric lacerations at normal vaginal deliveries. MATERIALS AND METHODS: A retrospective cohort study of all women with term vertex singleton pregnancies, who underwent normal vaginal deliveries, in a single tertiary hospital, between 2011 and 2015, was performed. The incidence of various obstetric lacerations was compared between deliveries with meperidine analgesia and deliveries with no analgesia. Deliveries with epidural analgesia and instrumental deliveries were excluded. An intravenous infusion of 75 mg of meperidine was administered together with 25 mg of promethazine. A multivariate logistic regression analysis was performed to assess the association between meperidine analgesia and obstetric lacerations, after controlling for confounders. RESULTS: Overall, 5227 (91.8%) deliveries with no analgesia and 466 (8.1%) deliveries with meperidine analgesia were included. Meperidine analgesia was associated with a decreased risk of first- and second-degree perineal lacerations (adjusted OR = 0.63, 95% CI = 0.49-0.81), and a decreased risk of any suturing (adjusted OR = 0.73, 95% CI = 0.59-0.91), after controlling for confounders. Meperidine analgesia did not affect the risk of severe perineal lacerations or episiotomies. CONCLUSION: Meperidine analgesia may have a protective effect against first- and second-degree perineal lacerations.

Respiratory events with sugammadex vs. neostigmine following laparoscopic sleeve gastrectomy: a prospective pilot study assessing neuromuscular reversal strategies.

Abdominal surgery in obese patients may be associated with pulmonary morbidity, and mortality. Some patients may arrive in the PACU with residual paralysis. The purpose of this study was to find out if there was an association between the type of muscle relaxant reversal agent and the development of postoperative respiratory events in patients undergoing laparoscopic sleeve gastrectomy surgery. METHODS: From September 2012 to February 2013, in a prospective randomized pilot study, two different muscle relaxant reversal agents were administered at the end of surgery in 57 patients undergoing laparoscopic sleeve gastrectomy: sugammadex 2 mg/kg (32 patients) vs. neostigmine 2.5 mg (25 patients). We compared the occurrence of early and late respiratory events/complications by the type of reversal agent. Postoperative respiratory rate, oxyhemoglobin saturation (SpO2), number of patients with SpO2 lower than 95% in PACU, the minimum value of SpO2 in PACU, train-of four counts (TOF) before reversal, unexpected ICU admissions, duration of hospitalization and incidence of reintubation were recorded. RESULTS: SpO2 in the PACU was significantly lower in the neostigmine group - 95.80 (± 0.014)) vs. in sugammadex group - 96.72 (± 0.011) (p < 0.01), despite a lower TOF count measured in the sugammadex group before reversal, meaning a deeper level of residual relaxation in this group before the administration of the reversal agent (2.53 ± 0.98 vs. 3.48 ± 0.58 p < 0.01). Also, the minimal SpO2 was significantly lower in the PACU in the neostigmine group: 93% vs. 94% (p = 0.01). Respiratory rates were not different. After the administration of reversal, both groups had TOF counts of 4 with no fade assessed visually. There were no postoperative respiratory events or complications. CONCLUSIONS: The use of sugammadex (as compared to neostigmine) as a reversal agent following laparoscopic sleeve gastrectomy surgery was associated with higher postoperative SpO2 despite the lower TOF count before the administration of reversal agent. Despite the statistical difference in SpO2, its clinical importance seems to be minimal. The lack of difference in the other measured variables may stem from the small number of patients studied (pilot).

Evaluation of the Temple Touch Pro, a Novel Noninvasive Core-Temperature Monitoring System.

BACKGROUND: The Temple Touch Pro (TTP) is a novel system that estimates core temperature from skin over the temporal artery. We tested the hypothesis that this noninvasive system estimates core temperature to an accuracy within 0.5°C. METHODS: Core temperature was continuously monitored in 50 adult and pediatric surgical patients by positioning the sensor patch of a TTP over one temporal artery. The sensor consists of a thermistor array near the skin surface, another set of thermistors above an insulator, and a second insulator between the upper unit and the environment. The sensor measures skin temperature and heat flux, from which the monitor unit estimates core temperature from a proprietary algorithm. Reference core temperature was measured from the esophagus or nasopharynx. We conducted agreement analysis between the TTP and the reference core temperature measurements using the 95% Bland-Altman limits of agreement for repeated measurement data. The proportion of all differences that were within 0.5°C and repeat measures concordance correlation coefficient (CCC) were estimated as well. RESULTS: TTP and the reference core temperature measurements agreed well in both adults and pediatric patients. Bland-Altman plots showed no evidence of systematic bias or variability over the temperature from 35.2°C to 37.8°C. The estimated 95% lower and upper limits of agreement were -0.57°C (95% confidence interval [CI], -0.76 to -0.41) and 0.57°C (95% CI, 0.44 to 0.71), indicating good agreement between the 2 methods. Ninety-four percentage (95% CI, 87% to 99%) of the TTP temperatures were within 0.5°C of the reference temperature. Good agreement was also supported by an estimated repeated measures CCC of 0.82 (95% CI, 0.66 to 0.91). The TTP core temperature measurements also agreed well with nasopharyngeal reference temperatures. CONCLUSIONS: The noninvasive TTP system is sufficiently accurate and reliable for routine intraoperative core temperature monitoring.

Does Body Mass Index Reduction by Bariatric Surgery Affect Laryngoscopy Difficulty During Subsequent Anesthesia?

BACKGROUND: The effect of body mass index (BMI) reduction following bariatric surgery on subsequent airway management has not been investigated. This study aimed to investigate the association between BMI reduction and airway assessment and management measured by Mallampati class (MC) and laryngoscopy grade (LG). METHODS: We conducted a retrospective study over 6 years to compare the BMI changes, MC and LG in patients having weight reduction bariatric surgery followed by subsequent surgery. Data was extracted from the anesthesia records of patients undergoing laparoscopic band insertion (LBI) and laparoscopic sleeve gastrectomy (LSG). Difficult airway was defined as Malampati class 3 and 4 on a 1-4 difficulty scale or laryngoscopy grade >2 on a 1-4 difficulty scale and need for unplanned fiberoptic intubation. Changes in these variables were correlated with weight reduction. Statistical analysis included t test, univariante, and multivariant logistic regression. RESULTS: Five hundred forty-six patients underwent LSG and 83 patients had LBI during the study period. Of those patients, 65 patients had subsequent surgical procedures after the bariatric procedure. Of the 65 patients identified, 62 were eligible. BMI decreased by approximately13 kg/m2 (p = 0.000) which roughly represents a 30 % reduction between the two surgical procedures. Mallampati class decreased significantly (p = 0.000) while laryngoscopy grade did not (p = 0.419). CONCLUSION: Our study revealed that a significant reduction in BMI was associated with a significant decrease in Mallampati class. There was no significant decrease in laryngoscopy grade, and there was no case of unplanned fiberoptic intubation.

Oxygen Reserve Index: A Novel Noninvasive Measure of Oxygen Reserve--A Pilot Study.

BACKGROUND: Pulse oximetry provides no indication of downward trends in PaO2 until saturation begins to decrease. The Oxygen Reserve Index (ORI) is a novel pulse oximeter-based nondimensional index that ranges from 1 to 0 as PaO2 decreases from about 200 to 80 mmHg and is measured by optically detecting changes in SvO2 after SaO2 saturates to the maximum. The authors tested the hypothesis that the ORI provides a clinically important warning of impending desaturation in pediatric patients during induction of anesthesia. METHODS: After preoxygenation, anesthesia induction, and tracheal intubation, the anesthesia circuit was disconnected and oxygen saturation was allowed to decrease to 90% before ventilation recommenced. The ORI and SpO2 values were recorded from a Masimo Pulse Co-Oximeter Sensor at the beginning of apnea, beginning and end of intubation, beginning and end of the ORI alarm, and 2 min after reoxygenation. RESULTS: Data from 25 healthy children, aged 7.6 ± 4.6 yr, were included in the analysis. During apnea, the ORI slowly and progressively decreased over a mean of 5.9 ± 3.1 min from 0.73 ± 0.16 at the beginning of apnea to 0.37 ± 0.11. SpO2 remained 100% throughout this initial period. Concurrently with alarm activation, the ORI began to decrease rapidly, and in median of 31.5 s (interquartile range, 19 to 34.3 s), saturation decreased to 98%. CONCLUSIONS: In this pilot study, the ORI detected impending desaturation in median of 31.5 s (interquartile range, 19-34.3 s) before noticeable changes in SpO2 occurred. This represents a clinically important warning time, which might give clinicians time for corrective actions.

Sugammadex: An Update.

The purpose of this update is to provide recent knowledge and debates regarding the use of sugammadex in the fields of anesthesia and critical care. The review is not intended to provide a comprehensive description of sugammadex and its clinical use.

Postoperative Takotsubo cardiomyopathy triggered by intraoperative fluid overload and acute hypertensive crisis.

The Takotsubo cardiomyopathy is a rare haemodynamic dysfunction, only recently reported perioperatively. While the diagnostic criteria have been established and the outcome is known as favorable, the pathophysiological mechanisms are not entirely understood. Here we present the case of a patient scheduled for laparoscopic hysterectomy and adnexectomy, who early postoperatively developed a Takotsubo cardiomyopathy supposedly triggered by an acute hypertensive crisis due to intraoperative fluid overload.

Residual Curarization and Postoperative Respiratory Complications Following Laparoscopic Sleeve Gastrectomy. The Effect of Reversal Agents: Sugammadex vs. Neostigmine.

BACKGROUND: Incomplete muscle relaxant reversal or re-curarization may be associated with postoperative respiratory complications. In this retrospective study we compared the incidence of postoperative residual curarization and respiratory complications in association with the type of muscle relaxant reversal agent, sugammadex or neostigmine, in patients undergoing laparoscopic sleeve gastrectomy. MATERIAL AND METHODS: We reviewed the charts of all patients (179) undergoing laparoscopic sleeve gastrectomy from July 2012 to July 2013 at Wolfson Medical Center. Sugammadex 1.5-2 mg/kg (112 patients) or neostigmine 2.5 mg (67 patients) were used as reversal agents. Results were compared by the type of reversal agent employed. Compared parameters included demographic and anaesthetic data, residual curarization, oxyhemoglobin saturation (SpO2) in the recovery room (PACU), episodes of SpO2 lower than 90% in PACU, unexpected intensive care (ICU) admissions, incidence of atelectasis and pneumonia, re-intubation and duration of hospitalization. RESULTS: Obstructive sleep apnea syndrome (OSAS) was more frequent in the sugammadex group (19% vs. 8%; p = 0.026). Total intravenous anesthesia (TIVA) was more frequently associated with sugammadex (33% vs. 16%; p = 0.007). There were no differences in postoperative residual curarization, SpO2 < 90% episodes, reintubation, ICU admissions, pulmonary complications and duration of hospitalization. CONCLUSION: With the inherent limitations of a retrospective study, the use of sugammadex following laparoscopic sleeve gastrectomy showed no advantage over neostigmine in terms of residual curarization and respiratory complications.

Morbidity and mortality after major pulmonary resections in patients with locally advanced stage IIIA non-small cell lung carcinoma who underwent induction therapy.

BACKGROUND: The optimal treatment for patients with locally advanced stage IIIA non-small cell lung carcinoma (NSCLC) remains controversial, but induction therapy is increasingly used. The aim of this study was to evaluate mortality, morbidity, hospital stay and frequency of postoperative complications in stage IIIA NSCLC patients that underwent major pulmonary resections after neoadjuvant chemotherapy or chemoradiation. METHODS: We conducted a retrospective analysis of all patients who underwent major pulmonary resections after induction therapy for locally advanced NSCLC from October 2009 to February 2014. Forty-one patients were included in the study. RESULTS: Complete resection was achieved in 40 patients (97.5%). A complete pathologic response was seen in 10 patients (24.4%). Mean hospital stay was 17.7 days (ranged 5-129 days). Early (in-hospital) mortality occurred in 2.4% (one patient after bilobectomy), late (six months) mortality in 4.9% (two patients after right pneumonectomy and bilobectomy), and overall morbidity in 58.5% (24 patients). Postoperative complications included: bronchopleural fistula (BPF) with empyema - three patients, empyema without BPF - five patients, air leak - eight patients, atrial fibrillation - eight patients, pneumonia - eight patients, and lobar atelectasis - four patients. CONCLUSION: Following neoadjuvant therapy for stage IIIA NSCLC, pneumonectomy can be performed with low early and late mortality (0% and 5.8%, respectively), bilobectomy is a high risk operation (16.7% early and 16.7% late mortality); and lobectomy a low risk operation (0% early and late mortality). The need for major pulmonary resections should not be a reason to exclude patients from a potentially curative procedure if it can be performed with acceptable morbidity and mortality rates at an experienced medical centre.

Effect of Surgical Safety checklist implementation on the occurrence of postoperative complications in orthopedic patients.

BACKGROUND: Surgical adverse events are errors that emerge during perioperative patient care. The World Health Organization recently published "Guidelines for Safe Surgery." OBJECTIVES: To estimate the effect of implementation of a safety checklist in an orthopedic surgical department. METHODS: We conducted a single-center cross-sectional study to compare the incidence of complications prior to and following implementation of the Guidelines for Safe Surgery checklist. The medical records of all consecutive adult patients admitted to the orthopedics department at Wolfson Medical Center during the period 1 July 2008 to 1 January 2009 (control group) and from 1 January 2009 to 1 July 2009 (study group) were reviewed. The occurrences of all complications were compared between the two groups. RESULTS: The records of 760 patients (380 in each group) hospitalized during this 12 month period were analyzed. Postoperative fever occurred in 5.3% versus 10.6% of patients with and without the checklist respectively (P = 0.008). Significantly more patients received only postoperative prophylactic antibiotics rather than both pre-and postoperative antibiotic treatment prior to implementation of the checklist (3.2% versus 0%, P = 0.004). In addition, a statistically non-significant 34% decrease in the rate of surgical wound infection was also detected in the checklist group. In a logistic regression model of postoperative fever, the checklist emerged as a significant independent predictor of this outcome: odds ratio 0.53, 95% confidence interval 0.29-0.96, P = 0.037. CONCLUSION: A significant reduction in postoperative fever after the implementation of the surgical safety checklist occurred. It is possible that the improved usage of preoperative prophylactic antibiotics may explain the reduction in postoperative fever.

Cough, expiration and aspiration reflexes: possible anesthetic implications - a brief review.

Systematic study in animals indicated, that in addition to cough there are 2 distinct airway reflexes. The aspiration reflex (AspR) characterized by rapid and strong gasp-like inspiration provoked by stimulation of nasopharynx, nasal phyltrum or auricle of ear. The expiration reflex (ExpR) manifests by prompt expiration, induced by laryngeal stimulation. Both reflexes strongly activate the brainstem inspiratory or expiratory generators, respectively, and inhibit the opposite respiratory and various functional disorders. This paper indicates several functional disorders occurring during manipulation with airways in anaesthesiological practice, which can be influenced positively or negatively by application of these special reflexes (asphyxia, breath-holding, laryngospasm, bronchospasm, sleep apnoea episodes, arrhythmia, collapse, etc.). The AspR, ExpR and CR (cough reflex) have important clinical relevance in anaesthesia and emergency medicine applicable also in domestic therapy and in hardly accessible places particularly by application of ICT (Information & Communication Technologies) using a mobile connection of the patient with the remote hospital centre.

The i-gel as a conduit for the Aintree intubation catheter for subsequent fiberoptic intubation.

We report a clinical case of an 128 kg, 53 year old male, who was scheduled for sleeve gastrectomy surgery. Video laryngoscope (GlideScope - Verathron) assisted intubation was attempted. Despite repositioning of the head and neck and external laryngeal manipulations, two attempts to lift the epiglottis were unsuccessful. An i-gel (Intersurgical, Wokingham, Berkshire, United Kingdom) supraglottic device was successfully placed and normal oxygenation and ventilation was established with pressure controlled ventilation. An Aintree intubation catheter (AIC, Cook Medical, USA) pre-loaded onto a pediatric fiberoptic bronchoscope (FOB) was advanced through the i-gel. After fiber optic visualization of the vocal cords, the AIC and FOB were successfully placed into the patient's trachea. We conclude that the i-gel may not only serve as a substitute for failed tracheal intubation, but is also useful as a conduit for subsequent fiberoptic intubation.

Video-assisted thoracic surgery lobectomy versus lobectomy by thoracotomy for lung cancer: pilot study.

OBJECTIVE: Video-assisted thoracic surgery lobectomy (VATS-L) has become accepted as a safe and effective procedure to treat early-stage non-small cell lung carcinoma (NSCLC). However, the advantages of VATS-L compared with lobectomy by thoracotomy (TL) remain controversial. The aim of this study was to compare the outcomes of patients who underwent VATS-L with those who underwent TL. METHODS: We studied 103 patients who underwent surgery for operable NSCLC between October 2009 and March 2012. All operations were performed by a single surgeon. The inclusion and exclusion criteria for VATS-L and TL were formulated before the study was initiated. Data on age, sex, preoperative comorbidities, intraoperative and postoperative complications, hospital stay, morbidity, mortality, and other characteristics were recorded preoperatively, in real time intraoperatively, and during hospitalization and were statistically compared. Comorbidities were scaled according to the Charlson Comorbidity Index, and propensity scores between the patients who underwent TL and VATS-L were compared. RESULTS: Sixty-three VATS-L operations and 40 TL operations were performed. There were no postoperative complications in 39 patients (61.9%) who underwent VATS-L compared with 25 patients (62.5%) who underwent TL. The patients who underwent TL were significantly younger than the patients who underwent VATS-L (mean ± SD, 64.7 ± 12.6 vs 70.9 ± 8.4; P = 0.003). Hospital stay was not found to be related to the type of surgery (mean ± SD, 8.43 ± 3.15 days vs 8.32 ± 4.13 days; P = 0.888). There were no significant differences when comparing postoperative complications. CONCLUSIONS: Our initial data suggest that VATS-L is a safe procedure in patients with resectable IA/IB NSCLC and may be the preferred strategy for treatment of the older patient population.