ABSTRACT
Cavernous haemangiomas are benign vascular malformations that can locate in the central nervous system. The epidural spinal location remains unusual. Pregnancy is known to be a precipitating factor. The aim of this study is to review general aspects of these lesions and specific facts about their relationship to pregnancy. A 32-year-old full-term pregnant woman is managed during early labor for a progressive spinal cord compression syndrome. After delivery, exploration by a lumbar MRI found an epidural vascular dorsal mass. Surgical exploration and histopathological examination confirmed the diagnosis of epidural cavernous haemangioma. The patient achieved complete recovery after 1 month. Spinal cavernous haemangiomas are rare malformations. Specific mechanisms seems to be involved in their growth during pregnancy. Although clinical and radiological presentation are spectacular and misleading, the prognosis is generally good, and urgent surgical treatment during pregnancy is usually not indicated.
Subject(s)
Epidural Neoplasms/diagnosis , Hemangioma, Cavernous, Central Nervous System/diagnosis , Pregnancy Complications, Neoplastic/diagnosis , Adult , Epidural Neoplasms/pathology , Epidural Neoplasms/surgery , Female , Hemangioma, Cavernous, Central Nervous System/pathology , Hemangioma, Cavernous, Central Nervous System/surgery , Humans , Magnetic Resonance Imaging , Pregnancy , Pregnancy Complications, Neoplastic/pathology , Pregnancy Complications, Neoplastic/surgery , Prognosis , Spinal Cord Compression/etiologyABSTRACT
The purpose of this study was to assess the effects of using a real time clinical decision-support system, "Assisted Fluid Management" (AFM), to guide goal-directed fluid therapy (GDFT) during major abdominal surgery. We compared a group of patients managed using the AFM system with a historical cohort of patients (control group) who had been managed using a manual GDFT strategy. Adherence to the protocol was defined as the relative intraoperative time spent with a stroke volume variation (SVV) < 13%. We hypothesised that patients in the AFM group would have more time during surgery with a SVV < 13% compared to the control group. All patients had a radial arterial line connected to a pulse contour analysis monitor and received a 2 ml/kg/h maintenance crystalloid infusion. Additional 250 ml crystalloid boluses were administered whenever measured SVV ≥ 13% in the control group, and when the software suggested a fluid bolus in the AFM group. We compared 46 AFM-guided patients to 38 controls. Patients in the AFM group spent significantly more time during surgery with a SVV < 13% compared to the control group (median 92% [82, 96] vs. 76% [54, 86]; P < 0.0005), and received less fluid overall (1775 ml [1225, 2425] vs. 2350 ml [1825, 3250]; P = 0.010). The incidence of postoperative complications was comparable in the two groups. Implementation of a decision support system for GDFT guidance resulted in a significantly longer period during surgery with a SVV < 13% with a reduced total amount of fluid administered. Trial registration: Clinical Trials.gov (NCT03141411).
Subject(s)
Abdomen/surgery , Decision Support Systems, Clinical , Fluid Therapy/methods , Fluid Therapy/standards , Surgical Procedures, Operative/standards , Aged , Algorithms , Anesthesiology/methods , Female , Goals , Guideline Adherence , Humans , Intraoperative Care/methods , Male , Middle Aged , Monitoring, Intraoperative/methods , Monitoring, Physiologic/methods , Postoperative Complications , Prospective Studies , Surgical Procedures, Operative/methodsABSTRACT
Blood pressure management in the operating rooms (OR) and intensive care units (ICU) frequently involves manually titrated vasopressor therapy to an optimal range of mean arterial pressure (MAP). Ideally, changes in vasopressor infusion rates have to quickly follow variations in blood pressure measurements. However, such a tightly controlled feedback loop is difficult to achieve. Few studies have examined blood pressure control when vasopressor therapy is administered manually in OR and ICU patients. We extracted MAP data from 3623 patients (2530 from the ORs and 1093 from the ICU) on vasopressors from our electronic medical records. Coefficient of variation (= standard deviation/mean value) *100) was calculated and the values were additionally categorized into different MAP ranges (MAP < 60 mmHg, 60 < MAP < 80 and MAP > 80 mmHg). There was no statistically significant difference between both centres for MAP across all time points (80 ± 12 vs. 80 ± 16, P = 0.996, 95% CI -6 to 6). The coefficients of variation of MAP were 13.7 ± 5.4% and 18.4 ± 9.8% in the OR and in ICU respectively. Patients on vasopressors spent 48.8% treatment time with a MAP between 60 and 80 mmHg (11.2% time with MAP < 60 mmHg, and 40% with MAP > 80 mmHg). These results provide a reasonable baseline from which to establish whether 'reduced variability' may be achieved with a closed-loop vasopressor administration system.
