Fatal inhalation injury caused by airway fire during tracheostomy.

A 45-year-old man needed emergency tracheostomy and cranioplasty. He was intubated with a cuffed oral polyvinylchloride endotracheal tube and ventilated with 100% oxygen before tracheal incision. During opening of the trachea using diathermy, a popping sound was heard and flames originating from the tracheal incision were observed. The endotracheal tube was charred and its lumen had melted. Immediately after the incident, bronchofibroscopic examination revealed inhalation injury. After remaining for 8 weeks in hospital, the patient was transferred to a health care centre, where he was found dead in his bed.

Supplemental 80% oxygen does not attenuate post-operative nausea and vomiting after breast surgery.

BACKGROUND: Although supplemental oxygen has been shown to be as effective as ondansetron in the prevention of post-operative nausea and vomiting (PONV) in one study in abdominal surgery patients, the antiemetic efficacy of supplemental oxygen is controversial on the basis of studies with other patients. We compared the efficacy of 80% and 30% oxygen in decreasing PONV in breast surgery. Ondansetron was used as an active control. METHODS: Ninety patients were given a standardized sevoflurane anesthetic. They were randomly assigned to three groups: 30% oxygen in nitrogen and saline 2 ml intravenously (i.v.) at the end of surgery (group 30); 80% oxygen in nitrogen and saline 2 ml (group 80); and 30% oxygen in nitrogen and ondansetron 4 mg (group O). Oxygen was administered during surgery and up to 2 h after surgery. RESULTS: The incidence of total response (no retching or vomiting, no nausea) during the first 24 post-operative hours was not different between group 80 (17%) and group 30 (11%) but was higher in group O (43%) than in group 30 (P<0.05). Compared with group O, patients in group 80 experienced more vomiting during the study period 0-24 h (66% vs. 32%; P<0.05) and more nausea during the period 6-24 h (72% vs. 39%; P<0.05). There was no difference between the groups in their risk for PONV, pain scores, opioid consumption, or patient satisfaction. CONCLUSIONS: In this study, supplemental 80% oxygen administration failed to decrease PONV in breast surgery.

Supplemental oxygen for prevention of nausea and vomiting after breast surgery.

BACKGROUND: Administration of supplemental oxygen 80% has been shown to halve the incidence of postoperative nausea and vomiting (PONV). We tested the efficacy of supplemental oxygen 50% in decreasing the incidence of PONV after breast surgery. METHODS: One hundred patients receiving standardized sevoflurane anaesthesia were randomly assigned to two groups: oxygen 30% administration (Group 30); and oxygen 50% administration (Group 50). Oxygen was administered during surgery and for 2 h from the end of surgery. RESULTS: The incidence of PONV over 24 h after surgery showed no difference between the groups: 82% in Group 30 and 89% in Group 50. However, during the postoperative oxygen administration, eight patients vomited in Group 30, compared with none in Group 50 (P<0.05). After oxygen therapy ceased, there was no difference in the incidence of vomiting between the groups. Nausea and need for rescue antiemetics did not differ between the groups. CONCLUSION: The incidence of vomiting decreased during the short postoperative administration of supplemental oxygen 50%. However, perioperative oxygen 50% administration did not prevent PONV over the 24-h follow-up period in patients undergoing breast surgery performed under general anaesthesia.

Quality assurance in anaesthetic practice: comparison between two methods in detecting complications.

BACKGROUND: Reliable identification and documentation of complications is an essential part of a well-functioning quality system (QS) in anaesthetic practice. The criteria for the complications have to be appropriate. The QS of Kuopio University Hospital fulfils the ISO 9002 standard. The validity of the recordings in the QS was ascertained by comparing the routine recordings with external assessment. METHODS: Three types of complications were predefined: minor, severe and those specific for regional anaesthesia. A total of 1006 anaesthetic charts, including general, regional and intravenous anaesthesia, were randomly selected and retrospectively screened by an external assessor. The retrospective assessment of complications was compared to the recordings in the data management system for operative procedures (DMS) as a part of routine quality assurance. Cohen's kappa statistics was used to indicate agreement between two raters. RESULTS: Both methods identified complications in 115 procedures (11.4%). The methods, however, did not identify complications in same procedures. There was a fairly close agreement (P < 0.001) between the methods in detecting all (Cohen's kappa 0.72), minor (0.67) and severe (0.66) complications and those specific for regional anaesthesia (0.78). Fifty-eight complications were detected either by retrospective assessment or routine reporting, i.e. the two raters disagreed in 58 complications. Thirteen severe complications recorded in the DMS could not be retrospectively identified. The agreement did not depend on ASA class, the urgency or the length of procedures or on the type of anaesthesia. CONCLUSIONS: The agreement between external assessment and routine reporting was fairly good, however, there were still some relatively large differences. The selection and definitions of complications need to be reassessed.

Oral ondansetron, tropisetron or metoclopramide to prevent postoperative nausea and vomiting: a comparison in high-risk patients undergoing thyroid or parathyroid surgery.

BACKGROUND: Oral antiemetic prophylaxis may be a practical alternative to intravenous administration. Intravenous ondansetron and tropisetron prevent postoperative nausea and vomiting (PONV) at least as efficiently as traditional antiemetics, droperidol and metoclopramide. We tested the hypothesis that the incidence of PONV after oral ondansetron or tropisetron prophylaxis is lower compared with metoclopramide among high-risk patients. METHODS: In a prospective, double-blind study we studied 179 high-risk patients who received either ondansetron 16 mg, tropisetron 5 mg, or metoclopramide 10 mg orally 1 h before the operation. A standard general anesthetic technique and postoperative analgesia were used. The incidence of PONV and the need for rescue antiemetic medication was recorded for 24 h. RESULTS: In the postanesthesia care unit, the incidence of PONV was lower after premedication with tropisetron compared with ondansetron and metoclopramide (15%, 32% and 39%, respectively). The incidence of PONV during 0-24 h was the same in each group (68%, 58% and 75% in the ondansetron, tropisetron and metoclopramide group, respectively), but the incidence of vomiting was significantly lower after ondansetron (34%) and tropisetron (22%) prophylaxis compared with metoclopramide (53%). The need for additional antiemetics was significantly lower after tropisetron prophylaxis compared with metoclopramide. Patient satisfaction was significantly higher after tropisetron than after metoclopramide. CONCLUSIONS: In the initial period, the incidence of PONV was lower after premedication with oral tropisetron than after ondansetron or metoclopramide. Considering the entire 24-h postoperative period, the incidence of PONV was the same after all three premedications, but the incidence of vomiting was lower after oral ondansetron and tropisetron than after metoclopramide.

Peroperative treatment with i.v. ketoprofen reduces pain and vomiting in children after strabismus surgery.

BACKGROUND: Strabismus surgery is associated with both pain and vomiting. Ketoprofen is widely used in adults to treat acute pain, but there are only few reports of its use in children. This randomised, double-blind, placebo-controlled, parallel group study was designed to investigate the analgesic effect of i.v. ketoprofen and its effect on the incidence of vomiting in children after day-case strabismus surgery. METHODS: Fifty-nine ASA 1 children, aged 1-12 years, entered the study. After premedication with diazepam and glycopyrronium, anaesthesia was induced with fentanyl and propofol and maintained with isoflurane. After induction the children in the ketoprofen group received 1 mg kg-1 ketoprofen followed by an infusion of 1 mg kg-1 ketoprofen over 2 h. In the placebo group, children received 0.9% saline. The postoperative pain was assessed by the Maunuksela pain score (0 = no pain, 10 = worst possible pain). All children received fentanyl as a rescue analgesic if the Maunuksela score was > or = 3. RESULTS: In the ketoprofen group the number of fentanyl doses was smaller compared to the placebo group (median 1, quartiles (0-2) vs. 2 (1-3), P = 0.047). The children in the ketoprofen group had less pain at 30 min (P = 0.02) and the worst pain observed in the post anaesthesia care unit was lower (3 (0-6) vs. 5 (3-8), P = 0.035). The incidence of vomiting was less in the ketoprofen group compared to the placebo group (17% vs. 41%, P = 0.036). No serious adverse reactions occurred. CONCLUSION: We concluded that ketoprofen administered i.v. during the operation produced analgesia and reduced opioid consumption and the incidence of vomiting in children after strabismus surgery.

Ultrasonography of the ureter during laparoscopic, abdominal and radical hysterectomy.

OBJECTIVE: To examine, by perioperative ultrasonography, ureteral anatomy and function during laparoscopic, abdominal and radical hysterectomy. SUBJECTS: The study group consisted of 36 patients scheduled for laparoscopic, abdominal or radical hysterectomy; there were 12 patients in each group. METHODS: The ureteral rest-phase diameter, maximal diameter during peristaltic waves and frequency of peristaltic waves were recorded immediately before and after hysterectomy under standard anesthetic conditions with the use of a 7.5-MHz linear laparoscopic ultrasound probe. RESULTS: Ureteral peristaltic activity was decreased and the rest-phase diameter was increased after hysterectomy. The findings were most evident after radical hysterectomy with pelvic lymphadenectomy. Retrograde (cranial) flow was recorded in a majority of the patients. The individual variation was great, particularly after radical surgery. Short- and long-term clinical outcome was normal in all cases. CONCLUSIONS: Uncomplicated hysterectomy is followed by changes in ureteral function. Although these changes apparently have no clinical significance, they must be recognized if laparoscopic ultrasonography is applied as a perioperative method to diagnose or exclude surgical ureteral lesions.

Comparison of tropisetron, droperidol, and saline in the prevention of postoperative nausea and vomiting after gynecologic surgery.

This study was performed to compare the efficacy of tropisetron, droperidol, and saline in the prevention of postoperative nausea and vomiting (PONV) and to compare the possible adverse effects of these drugs in gynecologic incontinence surgery. Using a randomized, double-blind study design, we studied 150 women undergoing gynecologic incontinence surgery with standardized general anesthesia. At the end of surgery, the patients received either tropisetron 5 mg, droperidol 1.25 mg, or 0.9% saline intravenously (i.v.). As a rescue antiemetic, the patients received metoclopramide 10 mg i.v.. The episodes of nausea, retching, and vomiting; the need for rescue treatment; and the type and severity of adverse events were recorded at four occasions during the 48-h observation period. Pain, anxiety, drowsiness, and general satisfaction were also evaluated on a linear numerical scale of 0-10. Complete response (no PONV within the 48-h observation period) occurred similarly in the study groups (tropisetron 25%, droperidol 22%, and placebo 18%). Tropisetron and droperidol had no effect on the incidence of nausea and retching. However, the incidence of vomiting was significantly less in the tropisetron group than in the placebo group (tropisetron 19%, droperidol 45%, and placebo 57%). The number of emetic episodes (retching and/or vomiting) per patient within 48 h was significantly decreased under tropisetron when compared with placebo (tropisetron 2.5 +/- 3.4, droperidol 4.2 +/- 6.1, placebo 5.9 +/- 7.1). With regard to adverse events, the patients in the droperidol group had significantly more anxiety than the placebo group (2-6 h postoperatively), more drowsiness than the tropisetron and placebo groups (0-2 h postoperatively), and more dissatisfaction than the tropisetron (0-6 h postoperatively) and placebo groups (2-6 h postoperatively). We conclude that tropisetron given 5 mg i.v. during anesthesia in gynecologic incontinence surgery effectively prevents vomiting but not nausea and retching, while 1.25 mg i.v. droperidol fails to prevent any of these emetic symptoms and results in adverse events.

Intracranial blood flow during laparoscopic hysterectomy.

AIM OF THE STUDY: To examine intracranial blood flow during major laparoscopic gynecologic operation and the effects of a deep Trendelenburg position and pneumoperitoneum on the flow. MATERIAL: Fifteen patients scheduled for laparoscopic hysterectomy. METHODS: Trans-cranial Doppler examination of blood flow velocity waveforms in the middle cerebral artery during operation. RESULTS: Trendelenburg position and pneumoperitoneum were followed by a decrease in cardiac output and an increase of central venous pressure and pulmonary capillary wedge pressure. No significant changes in the pulsatility index or maximal or mean blood flow velocities in the middle cerebral artery occurred during operations. A negative correlation between percentual changes in the pulsatility index and mean arterial pressure existed. CONCLUSIONS: Uncomplicated laparoscopic hysterectomy is not associated with harmful changes in intracranial circulation in spite of a Trendelenburg position, pneumoperitoneum and changes in the patient's extracranial hemodynamics.

Myocardial infarction in a parturient. A case report with emphasis on medication and management.

Myocardial infarction is rare in pregnancy. We report a 38-year-old woman with a history of smoking and pre-eclampsia in her previous pregnancy, who suffered a non-Q infarction at 18 weeks of gestation. Stenoses in the left coronary artery were verified angiographically. She delivered a healthy child vaginally under epidural anaesthesia.

Permanent blindness following retrobulbar hemorrhage after peribulbar anesthesia for cataract surgery.

We present a case in which a modified peribulbar anesthesia, administered with a 24-gauge (0.55 x 25 mm) sharp, disposable needle, induced an orbital hemorrhage, resulting in complete and permanent loss of vision. To our knowledge, this is the first report of severe complications following a peribulbar block.