Emergency Conversion to General Anesthesia Is a Tolerable Risk in Patients Undergoing Mechanical Thrombectomy.

BACKGROUND AND PURPOSE: Mechanical thrombectomy for acute ischemic stroke is performed with the patient under local anesthesia, conscious sedation, or general anesthesia. According to recent trials, up to 16% of patients require emergency conversion to general anesthesia during mechanical thrombectomy. This study investigated the procedural and clinical outcomes after emergency conversion in comparison with local anesthesia, conscious sedation, and general anesthesia. MATERIALS AND METHODS: This retrospective study included 254 patients undergoing mechanical thrombectomy for acute large-vessel occlusion. The procedure was started with the patient either under local anesthesia, conscious sedation, or general anesthesia. Emergency conversion was defined as induction of general anesthesia during mechanical thrombectomy. The primary outcomes were successful reperfusion (TICI 2b/3) and functional independence (mRS at 90 days, ≤2). RESULTS: Twenty-five patients (9.8%) required emergency conversion to general anesthesia. The time from admission to flow restoration was increased under general anesthesia (median, 137 minutes) and emergency conversion (median, 138 minutes) compared with local anesthesia (median 110 minutes). After adjustment for confounders, emergency conversion to general anesthesia and primary general anesthesia had comparable chances of successful reperfusion (OR = 1.28; 95% CI, 0.31-5.25). Patients with emergency conversion had a tendency toward higher chances of functional independence (OR = 4.48; 95% CI, 0.49-40.86) compared with primary general anesthesia, but not compared with local anesthesia (OR = 0.86; 95% CI, 0.14-5.11) and conscious sedation (OR = 1.07; 95% CI, 0.17-6.53). CONCLUSIONS: Patients with emergency conversion did not have lower chances of successful reperfusion or functional independence compared those with primary general anesthesia, and time to flow restoration was also similar. We found no evidence supporting the primary induction of general anesthesia in patients at risk for emergency conversion.

The adaptive value of gluttony: predators mediate the life history trade-offs of satiation threshold.

Animals vary greatly in their tendency to consume large meals. Yet, whether or how meal size influences fitness in wild populations is infrequently considered. Using a predator exclusion, mark-recapture experiment, we estimated selection on the amount of food accepted during an ad libitum feeding bout (hereafter termed 'satiation threshold') in the wolf spider Schizocosa ocreata. Individually marked, size-matched females of known satiation threshold were assigned to predator exclusion and predator inclusion treatments and tracked for a 40-day period. We also estimated the narrow-sense heritability of satiation threshold using dam-on-female-offspring regression. In the absence of predation, high satiation threshold was positively associated with larger and faster egg case production. However, these selective advantages were lost when predators were present. We estimated the heritability of satiation threshold to be 0.56. Taken together, our results suggest that satiation threshold can respond to selection and begets a life history trade-off in this system: high satiation threshold individuals tend to produce larger egg cases but also suffer increased susceptibility to predation.

Clinical and immunological spectrum of partial DiGeorge syndrome.

We present four cases of DiGeorge syndrome diagnosed at our center. Onset occurred during the neonatal period and was associated with severe congenital heart disease. In case 1, the patient had heart disease and absence of thymus. Total T-lymphocytes were 34%; total T4-lymphocytes were 27%. Stimulation test with phytohemagglutinin (PHA), concanavalin A (conA) and pokeweed mitogen were negative. Microdeletion was found in the chromosome 22q11 region. The second case involved heart disease, microstomia, round and rotated ears and branchial cyst. Total T-lymphocytes were 38% and total T4-lymphocytes 27%. Thymus was absent. Microdeletion in the chromosome 22q11 region. Case 3 showed heart disease, renal malformation, absence of thymus and parathyroid gland. The patient died 5 days postsurgery. Microdeletion was seen at chromosome 22q11. In the fourth case there was heart disease, microretrognathia, hypertelorism, short neck, absence of thymus and parathyroid glands. Total T-lymphocytes were 22%, total T4-lymphocytes 15%, and total T lymphocytes for pokeweed mitogen were negative. Microdeletion was found at chromosome 22q11. At the age of 13 days the patient died. The cases were recorded during a 2-year period, between 1997 and 1998. The prevalence of DiGeorge syndrome in the number of admissions for congenital heart disease among the neonates at our hospital was 3.14%. Presentation in the form of repeated infections is rare, since most cases of DiGeorge syndrome are partial, and functional cellular immunity is preserved.

[High-frequency oscillatory ventilation as salvage strategy in the newborn infant. Spanish multicenter study. I]. / Ventilación de alta frecuencia oscilatoria como estrategia de rescate en el recién nacido. Estudio multicéntrico Español. I.

OBJECTIVE: The aim of this study was to evaluate the results of high frequency ventilation (HFV) used as a rescue strategy in newborn infants with severe lung disease who either failed conventional mechanical ventilation (CMV) or had an air block. PATIENTS AND METHODS: From April 1995 to June 1998, 241 infants with severe lung disease and managed according to a common protocol of HFV used as a rescue strategy were prospectively evaluated in the nine participating level III Spanish Neonatal Intensive Care Units. The most frequent diagnoses were respiratory distress syndrome (119), meconium aspiration (24), pneumonia (19) and congenital diaphragm hernia (18). RESULTS: Mean +/- SD gestational age and birth weight were 32.0 +/- 5.5 weeks and 1,187 +/- 1,071 g, respectively. All babies were previously manages with CMV for a mean of 59 hours. HFV was started at a mean postnatal age of 82 hrs, with a mean oxygenation index (OI) of 28.3 +/- 15.3 and an a/A DO2 of 0.10 +/- 0.08. Initial mean HFV settings were: mean airway pressure 12.8 +/- 3.4 mbar, frequency 8.3 +/- 1.4 Hz, amplitude 53 +/- 20 percent, tidal volume 2.2 +/- 0.7 ml/kg and FiO2 0.88 +/- 0.2. At two hours of HFV there was a significant increase in the mean PaO2 (from 48 to 80 mmHg), with a concomitant decrease in FiO2 (from 0.88 to 0.79), PaCO2 (from 60 to 46 mmHg) and OI (from 28 to 18). Mean a/A DO2 increased from 0.10 to 0.19; these changes remained similar thereafter. HFV was suspended after a mean of 95 hrs because of improvement in 70%, death in 19% and failure to improve the clinical condition in the remaining 19%. Intrahospital death rate was 32%. The following complications were observed: pneumothorax (10%), interstitial emphysema (4%), intraventricular hemorrhage grades III and IV (14.5%) and bronchopulmonary dysplasia (35%). CONCLUSIONS: HFV is an effective rescue strategy that improves pulmonary gas exchange within two hours of its initiation.

[Simultaneous determination of total and immature neutrophil C-reactive protein in normal, diseased, and infected newborn infants]. / Determinación simultánea de la proteína C reactiva cuantitativa y de neutrófilos inmaduros en recién nacidos normales, patológicos e infectados.

C. reactive protein and immature neutrophils/total neutrophils ratio are measured in 146 newborns. Three groups are considered: 37 healthy, 90 pathologic non infected and 19 bacteriologically confirmed infected newborns. Pathologies other than infection do not alter CRP nor I/T. Levels lower than 20 mg/l for CRP and 0.18 for I/T are considered normal. Both tests are considered very useful for neonatal infection diagnosis (p less than 0.001). CRP shows a higher sensitivity than I/T in neonatal infection diagnosis even in its initial period (84% versus 63%).

[Perinatal histories of 22 newborns with malformations of the central nervous system]. / Valoración de la historia perinatal y de la conducta obstétrica en los embarazos de neonatos con malformaciones del sistema nervioso central.

The authors reviewed the perinatal histories of 22 newborns malformations of the central nervous system, among 9,323 consecutive births in the last five years, with particular emphasis on the incidence and types of malformations, as well as the most important findings of the parents anamnesis. Prenatal ultrasonography is stressed out as an important tool in the precocious diagnosis of such a kind of malformations.

[Pulmonary edema associated with Pseudomonas neonatal sepsis (author's transl)]. / Edema pulmonar lesional en la sepsis neonatal por Pseudomonas.

Four newborn babies at term, with massive pulmonary haemorrhage associated with fulminant septicemia due to pseudomonas, are presented. The neonates died in the first day of life. The haematocrit and the proteic contents of the pulmonary effluent showed the existence of a pulmonary lesional edema. The histological findings in the four cases support this hypothesis. A revision of the etiopathogenic possibilities of the noncardiogenic pulmonary edema in the neonate is presented.

[Persistance of fetal circulation. a case associated to maternal indomethacin administration (author's transl)]. / Persistencia de la circulación fetal. A propósito de un caso asociado a tratamiento materno con indometacina.

The case of a neonate born to a mother who was treated with indomethacin in the antenatal period is presented. Newborn presented, immediately after birth, severe respiratory distress syndrome, with cyanosis that remain unmodified by oxigenotherapy and mechanical ventilation. Clinical picture and analitic and radiographic findings, suggested persistent fetal circulation syndrome. It has been recently demonstrated that indomethacin is able to affect hemodynamic changes in neonatal period avoiding arteriolar dilatation and consequently, the fall of pulmonary vascular resistences. Administration of tolazoline was followed of rapidly improvement of the patient.

Ventilator modifications for intermittent mandatory ventilation.

A Loosko MK2 ventilator has been modified to provide IMV in newborns. IMV rate can be varied from 3-60/min. The minimum inspiration period can be theoretically as low as 0.1 sec. This modification in neonatal mechanical ventilation has been shown to be economically feasible.

[Fetal alcohol syndrome (author's transl)]. / Fetopatía alcohólica.

A case of fetal alcohol syndrome is reported in a intrauterine growth retarded female newborn with dysmorphic features and congenital cardiopathy whose mother suffered from a chronic ethylism during pregnancy. Authors compare this case findings with the reported revisions of other authors.

[Neonatal listeriosis. Apropos of 53 cases]. / Listériose néonatale. A propos de 53 cas.

53 cases of neonatal listeriosis were seen during the last five years at the Intensive Care Unit for newborn infants (Pr Minkowski) and the Neonatal Center (P. Varangot) of the Port-Royal Maternity Hospital. The significant decline in mortality to 22 p. 100, when compared with previous years, was attributed to improvements in the diagnosis during the first hours of life and the contribution of artificial ventilation. The most frequent initial clinical sign was respiratory distress (58 p. 100) whereas meningitis was relatively rare (11 p. 100). Discoloration of the amniotic fluid and a fever in the mother at the time of delivery, were also important diagnostic clues. The macroscopic examination of the placenta and particularly placental smears containing listeria monocytogenes (15 of the specimens) as well as the hematological alterations, particularly an increase of the fibrinogen level above 3-4 g/1 during the first 48 hous of life (72 p. 100 of the cases) contributed to an early diagnosis.