Serious Adverse Events after a Single Shot of Intrathecal Morphine: A Case Series and Systematic Review.

Background: The dose of intrathecal morphine is important because of its narrow therapeutic range. Due to a compounding error, pharmacy-compounded, ready-to-use syringes contained 1 mg ml-1 morphine instead of the intended 50 mcg ml-1. Six patients consequently received this twenty-fold dose. This study aims to describe the serious adverse events in these six patients and a systematic review is added to describe the characteristics of serious adverse events after intrathecal morphine. Methods: A retrospective case series described all six patients that received the erroneous morphine intrathecally for analgesia after laparoscopic segmental colonic resections. The patients' charts were reviewed for the occurrence, timing, duration and management of adverse events, the vital signs at the night after surgery, and length of hospital stay. A systematic review investigated characteristics of serious adverse events after intrathecal morphine in a perioperative setting. Results: Four patients had a serious adverse event, which was respiratory depression combined with somnolence (n = 3) and hypotension (n = 1). The review yielded 63 cases with serious adverse events, predominantly somnolence and/or respiratory depression. The onset occurred between 2 and 24 hours after injection. The severity of symptoms varied and life-threatening respiratory depression only occurred after a dose >900 mcg or when potentiating medication was used. Naloxone did not affect analgesia. No prolonged sequalae occurred. Conclusion: This study reveals that respiratory depression and somnolence are the predominant serious adverse events after intrathecal morphine in a perioperative setting and demonstrated a large variation in the presentation of symptoms.

Blind intubation through an i-gel® in the prone position: A prospective cohort study.

Accidental extubation in the prone position is a medical emergency in which quick and low resource demanding airway management is required. Regaining oxygenation is the primary goal, but sometimes intubation may be required to regain oxygenation. Blind intubation through an i-gel® (Intersurgical Ltd, Wokingham, Berkshire, UK) may be a quick and low resource demanding method. However, the success rate of the use of an i-gel as an intubation conduit in the prone position is unknown. This was a prospective study in patients scheduled for lumbar surgery. General anaesthesia was induced in the prone position and an i-gel was inserted. After successful ventilation, up to three attempts at intubation using a VivaSight-SL single-lumen tube (Ambu A/S, Ballerup, Denmark) were performed. The first attempt was blinded for the operator and the patient's head was in a neutral position. The second attempt was blinded for the operator with the patient's head rotated laterally. The third attempt was on-screen and allowed various manoeuvres to facilitate intubation. A success rate of 70% was deemed clinically acceptable. The study was terminated early after 14 subjects because the success rate of 70% was not achievable. However, ventilation using the i-gel in the prone position was successful in 13 patients (93%). Intubation was successful in only one patient at the first attempt, one patient at the second attempt and three patients at the third attempt. Overall, the success rate was 36%. Blind intubation using an i-gel as an intubation conduit in the prone position is not recommended.Netherlands Trial Register number NL6387 (NTR7659).

Can fMRI safely replace the Wada test for preoperative assessment of language lateralisation? A meta-analysis and systematic review.

Recent studies have shown that fMRI (functional magnetic resonance imaging) may be of value for pre-surgical assessment of language lateralisation. The aim of this study was to systematically review and analyse the available literature. A systematic electronic search for studies comparing fMRI with Wada testing was conducted in the PubMed database between March 2009 and November 2011. Studies involving unilateral Wada testing, study population consisting exclusively of children younger than 12 years of age or involving five patients or fewer were excluded. 22 studies (504 patients) were included. A random effects meta-analysis was conducted to obtain pooled estimates of the positive and negative predictive values of the fMRI using the Wada test as the reference standard. The impact of several study features on the performance of fMRI was assessed. The results showed that 81% of patients were correctly classified as having left or right language dominance or mixed language representation. Techniques were discordant in 19% of patients. fMRI and Wada test agreed in 94% for typical language lateralisation and in 51% for atypical language lateralisation. Language production or language comprehension tasks and different regions of interest did not yield statistically significant different results. It can be concluded that fMRI is reliable when there is strong left-lateralised language. The Wada test is warranted when fMRI fails to show clear left-lateralisation.

Hypercalcemia in patients with bipolar disorder treated with lithium: a cross-sectional study.

BACKGROUND: Lithium-induced hyperparathyroidism (LIH) is a relative underrecognized complication of long-term lithium treatment. Hypercalcemia may be the first, but often overlooked, sign of LIH. Symptoms of LIH can be similar to the underlying psychiatric illness, which may cause a significant doctor's delay in diagnosing LIH. The aim of this study was to determine the prevalence of hypercalcemia in a cohort of psychiatric patients. METHODS: In this cross-sectional study, we collected data from 314 patients treated with lithium in an outpatient clinic for bipolar disorder. Patients with bipolar disorder from the same clinics, who had never been treated with lithium and of whom serum calcium levels were available, were included as controls (n = 15). Patient characteristics and laboratory results were collected during the period of June 2010 till June 2011. RESULTS: The mean serum calcium level was 2.49 (SD 0.11) mmol/l. The point prevalence of hypercalcemia (>2.60 mmol/l) was 15.6%. In a comparable group of psychiatric patients not using lithium, the mean serum calcium level was 2.37 mmol/l, and none of these patients had hypercalcemia (p = 0.001). The duration of lithium treatment was the only significant predictor for the development of hypercalcemia (p = 0.002). DISCUSSION: The prevalence of hypercalcemia in lithium-treated patients was significantly higher than that in non-lithium treated controls and correlated to the cumulative time lithium was used in this cross-sectional study. We recommend that serum calcium levels should be routinely tested in patients using lithium for timely detection of LIH or hypercalcemia due to other causes.

[Lithium-induced hyperparathyroidism]. / Lithium-geïnduceerde hyperparathyreoïdie.

Lithium is a medication successfully being used for the treatment of bipolar disorder. Lithium-induced hyperparathyroidism (LIH) is a little known complication that may arise due to the use of lithium. Symptoms of LIH are often similar to the underlying psychiatric illness for which lithium was indicated. It is thus difficult to differentiate between these, resulting in significant 'doctors' delay' in the diagnosis of LIH. The authors present three cases in this article. In the first case concerning a 51-year-old woman, they illustrate that LIH and subsequent hypercalcaemia are often diagnosed by coincidence. In the second case concerning a 47-year-old woman, they show that it can be quite complicated to locate the underlying aberration of the parathyroid and that medication may be an eligible alternative to surgery. In the third case, a 56-year-old woman, they show the need for cogency regarding appropriate surgical strategy as recurrences are quite common.