An unusual case of Legionellosis.

Legionella species is a common cause of community-acquired pneumonia. However disease due to L. pneumophila serogroup 13 is rare and has not previously been reported in Ireland. It may not be detected by routine Legionella antigen and antibody kits. Due to these limitations, early culture should be considered when legionellosis is suspected. The potential therapeutic benefit of quinolones in the management of this disease is also illustrated.

The effect of midazolam on cerebral endothelial (P-selectin and ICAM-1) adhesion molecule expression during hypoxia-reperfusion injury in vitro.

BACKGROUND AND OBJECTIVE: Hypoxia-reperfusion injury is an important determinant of secondary brain injury. In the acute phase of cerebral reperfusion, pro-inflammatory events enhance expression of cerebral endothelial (intercellular adhesion molecule-1 and P-selectin) adhesion molecules, which play an important role in brain hypoxia-reperfusion injury. Midazolam is the most commonly used sedative in patients with brain injury. The objective of this investigation was to examine the effect of midazolam on the expression of cerebral endothelial intercellular adhesion molecule-1 and P-selectin during hypoxia-reperfusion injury in vitro. METHODS: The up-regulation of mouse cerebral endothelial cells intercellular adhesion molecule-1 and P-selectin was assessed following hypoxia-reoxygenation (hypoxia-reperfusion). Cells were pre-treated with three different concentrations of midazolam (0, 5 and 50 microg mL(-1)) prior to hypoxia. Flow cytometry was used to estimate adhesion molecule expression mean channel fluorescence. Data are presented as mean +/- SD. RESULTS: Mouse cerebral endothelial cell intercellular adhesion molecule-1 and P-selectin expression was greater after exposure to hypoxia-reoxygenation compared to normoxia (mean channel fluorescence) 241 +/- 12 vs. 140 +/- 7 and 120 +/- 14 vs. 46 +/- 7, respectively, P < 0.05. Intercellular adhesion molecule-1 and P-selectin expression was decreased by midazolam (5 microg mL(-1)) pre-incubation compared to control, mean channel fluorescence 184 +/- 10 vs. 241 +/- 12 and 51 +/- 7 vs. 120 +/- 14, respectively, P < 0.05. Midazolam at 50 microg mL(-1) had the same effect as 5 microg mL(-1). CONCLUSION: Pre-treatment with midazolam diminishes increased expression of cerebral endothelial intercellular adhesion molecule-1 and P-selectin expression following hypoxia-reoxygenation.

Skeletal muscle acidosis correlates with the severity of blood volume loss during shock and resuscitation.

BACKGROUND: Continuous assessment of tissue perfusion and oxygen utilization may allow for early recognition and correction of hemorrhagic shock. We hypothesized that continuously monitoring skeletal muscle (SM) PO2, PCO2, and pH during shock would provide an easily accessible method for assessing the severity of blood loss and the efficacy of resuscitation. METHODS: Thirteen anesthetized pigs (25-35 kg) underwent laparotomy and femoral vessel cannulation. Multiparameter fiberoptic sensors were placed in the deltoid (SM) and femoral artery. Ventilation was maintained at a PaCO2 of 40-45 mm Hg. Total blood volume (TBV) was measured using an Evans blue dye technique. Animals were bled for 15 minutes, maintained at a mean arterial pressure (MAP) of 40 mm Hg for 1 hour, resuscitated (shed blood + 2 times shed volume in normal saline) and observed for 1 hour. Four animals served as controls (sham hemorrhage). Blood and tissue samples were taken at each time point. RESULTS: Blood loss ranged from 28.5-56% of TBV. SM pH and SM PO2 levels fell rapidly with shock. SM PO2 returned to normal with resuscitation; however, SM pH did not return to baseline. SM PCO2 significantly rose with shock, but returned to baseline promptly with resuscitation. There was a significant correlation between SM pH and blood volume loss at end shock (r2 = 0.73, p < 0.001) and recovery (r2 = 0.84, p < 0.001). Animals (n = 2) whose SM pH did not recover to 7.2 were found to have ongoing blood loss from biopsy sites and persistent tissue hypercarbia despite normal MAP. CONCLUSION: Continuous multiparameter monitoring of SM provides a minimally invasive method for assessing severity of shock and efficacy of resuscitation. Both PCO2 and PO2 levels change rapidly with shock and resuscitation. SM pH is directly proportional to lost blood volume. Persistent SM acidosis (pH < 7.2) and elevated PCO2 levels suggest incomplete resuscitation despite normalized hemodynamics.

Metabolic management of patients with severe burns.

Burn injury results in profound metabolic abnormalities perpetuated by an exaggerated stress response to injury. Hypermetabolism and marked catabolism, with rapid erosion of lean body mass, becomes evident shortly after injury. Much of the morbidity and mortality of a major burn can be attributed to this process, which increases infection risks, decreases the healing rate, and alters cell function. Rapid removal of devitalized burn tissue combined with early aggressive nutritional support significantly attenuates this autodestructive process. The addition of anabolic agents decreases the degree of lean mass loss and increases the rate of restoration. Immediate attention to the metabolic response to a severe burn significantly decreases complications and improves outcome.

Anesthetic considerations for patients with severe emphysematous lung disease.

The pathophysiology, medical and surgical management of emphysema have been reviewed as a foundation to the physiological goals and principles of anesthetic management of patients with emphysema. An understanding of the cardiovascular and respiratory consequences of emphysema combined with anesthesia, PPV, and thoracic surgery is essential to achieving the challenging physiological goals of providing anesthesia, positive pressure and one-lung ventilation, and postoperative analgesia in a manner consistent with rapid postoperative extubation, hemodynamic stability, adequate gas exchange, and minimal barotrauma for this population of patients.

The effects of aprotinin on blood product transfusion associated with thoracic aortic surgery requiring deep hypothermic circulatory arrest.

OBJECTIVE: To compare the effects of aprotinin on blood product use and postoperative complications in patients undergoing thoracic aortic surgery requiring deep hypothermic circulatory arrest. DESIGN: A retrospective study. SETTING: A university hospital. PARTICIPANTS: Nineteen patients who underwent elective or urgent thoracic aortic surgery. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The total number of units of packed red blood cells, fresh frozen plasma, and platelets was significantly less in the group that received aprotinin (p = 0.01, 0.04, and 0.01). The intraoperative transfusion of packed red blood cells and platelets, collection and retransfusion of cell saver, and postoperative transfusion of fresh frozen plasma were also significantly less in the aprotinin group (p = 0.01, 0.02, 0.01, and 0.05). No patient in either group sustained renal dysfunction or a myocardial infarction. Two patients who had not received aprotinin suffered from chronic postoperative seizures, and one patient who had received aprotinin sustained a perioperative stroke. CONCLUSIONS: Low-dose aprotinin administration significantly decreases blood product transfusion requirements in the setting of thoracic aortic surgery requiring deep hypothermic circulatory arrest, and it does not appear to be associated with renal or myocardial dysfunction.

Pituitary apoplexy after spinal anaesthesia.

We report the case of a previously healthy 51-yr-old male who underwent an uneventful total hip replacement under spinal anaesthesia. His immediate postoperative course was complicated by the development of a severe frontal headache. Initial conservative treatment included oral analgesics and an epidural blood patch. The headache persisted and was followed by progressive vision loss and a right partial third nerve palsy. The patient was almost blind at the time of transfer to our neurosurgical unit. Relevant investigations revealed marked hyponatraemia (serum sodium concentration 122 mmol litre-1) and second-degree heart block (Mobitz I). A CT scan showed a pituitary tumour and confirmed the clinical diagnosis of pituitary apoplexy. Urgent craniotomy was scheduled and a large necrotic pituitary adenoma was excised. The postoperative course was uneventful with return of near normal vision at the time of discharge. Clinicians should consider this diagnosis when focal neurological deficits occur with post-dural puncture headache.

Total-body oxygen consumption after isoflurane anesthesia: effects of mild hypothermia and combined epidural-general anesthesia.

STUDY OBJECTIVES: To determine the effects of epidural anesthesia and avoidance of intraoperative heat loss on the increase in total-body oxygen consumption in the immediate postoperative period after major intraabdominal surgery. DESIGN: Prospective, randomized (with regard to temperature management) study. SETTING: University medical center. PATIENTS: 24 ASA physical status I, II, and III adults. INTERVENTIONS: All patients received either isoflurane-nitrous oxide (N2O)-opioid general anesthesia or combined epidural-general anesthesia; patients were randomly assigned to active intraoperative warming or routine thermal care. MEASUREMENTS AND MAIN RESULTS: VO2 was measured by indirect calorimetry preoperatively (T0), immediately postoperatively (T1), and 60 to 90 minutes later (T2). For all patients, VO2 was 57 +/- 45% (mean +/- SD) greater at T1 than at T0 (p < 0.05). After isoflurane-N2O-opioid general anesthesia, VO2 increased 15 +/- 20% in normothermic patients (core temperature, 36.4 +/- 0.2 degrees C) compared with 69 +/- 52% in hypothermic patients (35.0 +/- 0.5 degrees C). After combined epidural-general anesthesia, VO2 increased 86 +/- 39% on emergence in normothermic (36.4 +/- 0.2 degrees C) and 58 +/- 11% in hypothermic (35.1 +/- 0.4 degrees C) patients. CONCLUSIONS: Total-body VO2 was increased in the immediate postoperative period. After general anesthesia, the magnitude of the increase in VO2 was significantly less in normothermic patients than in hypothermic patients. After combined epidural-general anesthesia, VO2 was increased in normothermic and in hypothermic patients.

Interlocking intramedullary nailing for the treatment of tibial fractures.

Thirty-seven tibial shaft fractures in 34 patients were treated with the Grosse-Kempf interlocking intramedullary nail over a two year period. Thirty-six tibiae were consolidated at a median of 17 weeks; one had re-fractured following nail removal in a separate injury, but was now uniting on conservative treatment. Using very detailed clinical and radiological analysis, and excluding the patient who had re-fractured, the results were excellent in 19, good in 8, fair in 6 and poor in 3. The most significant complications were haematoma formation and additional comminution during nail insertion. Overall, we found tibial nailing to be a satisfactory procedure, facilitating rapid rehabilitation with early weight bearing and resulting in predictable fracture healing in good alignment.