Rapid correction of severe hyponatremia after hysteroscopic surgery ­ a case report.

BACKGROUND: One of the most feared complications during hysteroscopic surgery is haemodilution by absorption of distension media. One facet of haemodilution, i.e. hyponatremia, can lead to respiratory distress, pulmonary oedema, as well as cardiovascular collapse. CASE PRESENTATION: Here we report the swift recovery of a 45 year, female, Caucasian patient with acute hyponatremia (74 mEq/L) and pulmonary oedema by the employment of rapid correctional strategies. CONCLUSION: The absorption of irrigation fluids, as presented in this case, is an inevitable side effect of hysteroscopic surgery. Utmost caution should, therefore, be mandatory to reduce and actively monitor fluid intake. If these measures fail, as in the case presented here, it is essential to rapidly eliminate any free water and to normalize the sodium levels. Anecdotal reports of pontine myelinolysis are not in line with literature concerning acute hyponatremia and should, therefore, not obstruct determined action against it.

Assessment of hemostaseologic alterations induced by hyperbaric oxygen therapy using point-of-care analyzers.

BACKGROUND: Exposure to hyperbaric conditions influences the coagulation system. Thromboembolic events and disseminated intravascular coagulation were observed. OBJECTIVES: To detect the effects of a hyperbaric environment on the human coagulation system using the point-of-care coagulation analyzers Multiplate and ROTEM. PATIENTS/METHODS: 20 patients were included. Each received 90 minutes of oxygen intermittently at 2.4 atmospheres absolute, as per the TS 240-90 wound-healing protocol. Blood samples were taken before and after hyperbaric exposure and ROTEM, Multiplate and standard laboratory assays were subsequently performed. RESULTS: ROTEM showed a significant increase of the maximum clot firmness (EXTEM MCF; p < 0.05) and the thromboelastometric platelet component of the clot firmness (MCF(EXTEM) - MCF(FIBTEM); p < 0.01). Multiplate showed a platelet activation mediated by thrombin (AU TRAP-test; p < 0.05) and by arachidonic acid (AUC ASPI-test; p < 0.01). Standard laboratory assays revealed a lower activated partial thromboplastin time (p < 0.05) and a higher leukocyte count (p < 0.05). No further changes were detected. A t-test was performed after testing if data followed normal distribution. CONCLUSIONS: ROTEM and Multiplate were able to detect an activation of platelets after HBO2 therapy via thrombin and arachidonic acid pathways. Previously reported fibrinolysis could not be confirmed.

Anaesthesia in a patient with subarachanoidal haemorrhage and high oxygen affinity haemoglobinopathy (HB york): case report.

BACKGROUND: Approximately 90 haemoglobinopathies have been identified that result in abnormally high oxygen affinity. One of these is haemoglobinopathy York (HbY), first described in 1976. HbY causes an extreme leftward shift of the oxygen dissociation curve with the P50 value changing to 12.5 - 15.5 mmHg (normal value 26.7 mmHg), indicating that approximately half of the haemoglobin is not available as oxygen carrier. Patients with haemoglobinopathies with increased oxygen affinity could suffer from the risk developing ischaemic complications due to a lack of functional oxygen carriers. This is, to best of our knowledge, the first case report on a patient with HbY published in connection with anesthesia. CASE PRESENTATION: A 42-year-old female with a severe headache and Glasgow coma scale (GCS) of 15 was admitted to the neurosurgical intensive care unit with a ruptured, right sided ICA aneurysm with consecutive subarachnoid haemorrhage [Fisher III, World Federation of Neurosurgical Societies (WFNS) I)]. The medical history of the patient included an erythrocytosis (Hb 17.5 g/dl) on the base of a high-oxygen-affinity haemoglobinopathy, called Hb York (HbY). With no time available to take special preoperative precautions, rapid blood loss occurred during the first attempt to clip the aneurysm. General transfusion procedures, according to the guidelines based on haemoglobin and haematocrit values, could not be applied due to the uncertainty in the oxygen carrier reduction. To maintain tissue oxygen supply, clinical indicators of ischaemia were instead utilized to gauge the appropriate required blood products, crystalloids and colloids replacements. Despite this, the patient survived the neurosurgical intervention without any neurological deficit. CONCLUSIONS: Family members of patients with HbY (and other haemoglobinopathies with increased oxygen affinity) should undergo clinical assessment, particularly if they are polycythaemic. If the diagnosis of HbY is confirmed, they should carry an "emergency anaesthesiology card" in order to avert perioperative risks arising from their "hidden" anemia.

The paravertebral lamina technique: a new regional anesthesia approach for breast surgery.

STUDY OBJECTIVE: To test the feasibility and efficacy of a new approach to paravertebral catheter placement in patients undergoing major surgery of the breast. DESIGN: Single-group, single-center observational study. SETTING: Operating room, postoperative recovery area, and normal ward of a university hospital. PATIENTS: 25 ASA physical status 1, 2, 3, and 4 patients undergoing major unilateral surgery of the breast. INTERVENTIONS: Paravertebral catheters for intraoperative and postoperative anesthesia and analgesia were applied using the recently described lamina technique. This technique is performed at a more medial puncture site, avoiding the pleura. MEASUREMENTS: Additional opioid requirements were recorded to assess effectiveness of regional anesthesia. At the time of catheter withdrawal, patients, staff nurses, and anesthesiologists who provided postoperative pain management were asked to rate their satisfaction with paravertebral catheter effectiveness. MAIN RESULTS: All patients successfully received a paravertebral catheter using the lamina technique. During the surgical procedure, 84% of patients received no additional opioids after intubation. No patient required opioids as rescue medication postoperatively (visual analog scale rating > 30 mm) or during the rest of the hospital stay. Postoperative analgesia provided with paravertebral catheters was rated very high by patients, staff nurses, and anesthesiologists involved in postoperative care. CONCLUSIONS: The lamina technique for placement of a paravertebral catheter is a feasible and effective technique for intraoperative and postoperative analgesia in patients scheduled for major breast surgery with or without axillary lymph node resection.

The effectiveness of preformed tooth protectors during endotracheal intubation: an upper jaw model.

BACKGROUND: In anesthetic practice, tooth damage may impair patient safety and is a common reason for litigation. The use of dental shields may reduce this complication. In this study, we examined the effectiveness of dental shields for altering the force on the teeth during endotracheal intubation. METHODS: Five preformed dental shields (Endoragard, Ormco, Nouveau Dispositif (ND), PEB, and Camo) were evaluated in three different categories: (a) horizontal force reduction, (b) axial force reduction, and (c) impact on the view of the oral cavity. Force reduction was examined by using an upper jaw model. The upper incisors of the model were covered with each of the dental shields and then loaded with a force of 150 N via a blade of a laryngoscope directed to the maxillary left central incisor (tooth 9). The force distributed to the four maxillary central and lateral incisors by the dental shield was also measured by strain gauges placed to estimate the force applied to each tooth. The reduction in oral view was determined by measuring the thickness of each dental shield with a micrometer. RESULTS: Dental shield Ormco Sports-Guard achieved the highest force reduction results, followed by Camo and Endoragard. ND and PEB showed poor, but statistically significant, force reduction with either the worst axial (ND) or horizontal (PEB) results. In contrast, Ormco was the most voluminous model, followed by ND and Camo. PEB and Endoragard were the thinnest models. CONCLUSIONS: Preformed dental shields are useful to reduce the force applied to the teeth and potentially reduce the probability of tooth damage during laryngoscopy. However, the shield with the most force reduction capability is rather large and also expensive, making general use impossible. Further prospective studies are needed to evaluate efficacy and safety of tooth protectors.

Broken guide wire--a fault of design?

PURPOSE: To report a potentially serious complication resulting from a faulty guide wire during central venous catheterization. CLINICAL FEATURES: We report breakage of a guide wire with potential severe implications for a 47-yr-old critical care patient. The tip of the J-wire became lodged in the internal jugular vein, and required fluoroscopic guidance for removal, which occurred without complication. CONCLUSION: Breakage of a guide wire during central venous catheter insertion has been very rarely reported. However, inherent faults in design or in the manufacturing process of the guide wire could lead to this rare complication. A simple bedside test is proposed to detect breakage in the core section of the guide wire.