The role of liver resection in the management of severe blunt liver trauma.

BACKGROUND: The management of hepatic trauma has a historical progress from mandatory operation with selective non-operative treatment, to non-operative treatment with selective operation. Liver resection (LR) seems to have a minimal role in the management of liver injury. However, surgical treatment becomes the only life-saving treatment in cases with severe liver trauma. METHODS: It is a retrospective presentation of five cases with severe blunt liver injury whose were admitted at our center during the 8-year period. RESULTS: The median age of patients was 30.8 (23-43). The most frequent mechanism of injury was pedestrian struck (60%). Two of five cases were transferred to our hospital from rural state hospitals after initial attempt to achieving hemostasis. The majority of liver injury was grade V (80%). The right lobe of the liver was injured in different extensions. Major vascular injury was associated to liver injury in four of five cases. The right hepatectomy (n=1), resectional debridement of segments 5, 6, and 7 (n=1), posterior sectorectomy (n=2), and segment 7 resection (n=1) were performed for hemostasis. Vascular injuries in the junction of inferior vena cava and right hepatic vein (n=1), the anterior surface of the right hepatic vein (n=1), the junction of segment 7 hepatic vein and right hepatic vein (n=1), the main portal vein (n=1), and the right renal vein (n=1) were repaired. Median operation time was 162 min (120-180 min). Operative mortality was 20%. Reoperation was needed in three of four survived cases. In-hospital complications were observed in two of four survived cases. Median stay in intensive care unit and hospital was 12.4 days (1-48 days) and 28.2 days (1-65 days), respectively. CONCLUSION: When a severe liver injury is unresponsive to packing, the surgeon must always keep in mind that extensive maneuvers for vascular control and LR are required for bleeding control.

Comparison of Thoracic Epidural Analgesia and Traditional Intravenous Analgesia With Respect to Postoperative Respiratory Effects in Cardiac Surgery.

OBJECTIVES: Surgical stress and pain affect the respiratory condition of patients and can cause complications that affect morbidity and mortality in cardiac surgeries. The authors studied the effect of thoracic epidural analgesia (TEA) versus traditional intravenous analgesia on postoperative respiratory mechanics in cardiac surgery. DESIGN: Retrospective, observational study. SETTING: Single, university hospital. PARTICIPANTS: Patients undergoing cardiac surgery. INTERVENTIONS: Comparing the postoperative respiratory effects of TEA with bupivacaine or intravenous analgesia with tramadol or paracetamol or dexmedetomidine. MEASUREMENTS AND MAIN RESULTS: A total of 1,369 patients were screened, and 1,280 patients were enrolled in the study. Postoperative sedation and analgesia level, extubation times, respiratory complications, lengths of intensive care and hospital stay, morbidity, and mortality were compared. Additional sedative and analgesic drug requirement in the TEA group (25.3% and 60.1% respectively) were significantly lower than the intravenous group (41.4% and 71.8%, respectively; p < 0.001 and p < 0.05, respectively). Extubation time in the TEA group also was significantly lower than the intravenous group (p < 0.01). Respiratory complication and hospital stay in the TEA group were lower than intravenous group (p < 0.05). CONCLUSIONS: TEA provided better postoperative respiratory condition via better sedative analgesia in cardiac surgery.

Does the addition of tramadol and ketamine to ropivacaine prolong the axillary brachial plexus block?

BACKGROUND AND OBJECTIVES: A prospective, randomized, controlled, double-blind clinical trial to assess the effect of tramadol and ketamine, 50 mg, added to ropivacaine in brachial plexus anesthesia. METHODS: Thirty-six ASA physical statuses I and II patients, between 18 and 60 years of age, scheduled for forearm and hand surgery under axillary brachial plexus block, were allocated to 3 groups. Group R received 0.375% ropivacaine in 40 mL, group RT received 0.375% ropivacaine in 40 mL with 50 mg tramadol, and group RK received 0.375% ropivacaine in 40 mL with 50 mg ketamine for axillary brachial plexus block. The onset times and the duration of sensory and motor blocks, duration of analgesia, hemodynamic parameters, and adverse events (nausea, vomiting, and feeling uncomfortable) were recorded. RESULTS: The onset time of sensorial block was the fastest in ropivacaine + tramadol group. Duration of sensorial and motor block was the shortest in the ropivacaine + tramadol group. Duration of analgesia was significantly longer in ropivacaine + tramadol group. CONCLUSION: We conclude that when added to brachial plexus analgesia at a dose of 50 mg, tramadol extends the onset and duration time of the block and improves the quality of postoperative analgesia without any side effects.

Antibacterial effects of fluoride varnish compared with chlorhexidine plus fluoride in disabled children.

PURPOSE: To evaluate the effects of fluoride varnish vs a combination of chlorhexidine-thymol varnish plus a gel containing chlorhexidine and fluoride on oral hygiene and caries prevention in disabled children. MATERIALS AND METHODS: Ninety patients aged 3-17 years who were treated under general anaesthesia were randomly assigned into three groups as follows: group 1: Fluor Protector (0.1% fluoride varnish); group 2: Cervitec Plus (1% chlorhexidine- 1% thymol varnish) + Cervitec Gel (0.2% chlorhexidine-0.2% sodium fluoride); group 3: control (toothbrushing only). Mutans streptococci (MS) and lactobacilli (LB) levels, visible plaque index (VPI) and gingival bleeding index (GBI) were evaluated at four stages: T0, before general anaesthesia; T1, one month after treatment; T2, six months after treatment; T3, twelve months after treatment. The data were evaluated using Kruskal-Wallis and Mann-Whitney U-tests (P < 0.05). RESULTS: Groups 1 and 2 showed significantly lower scores than group 3 for all parameters at T1 and T2. No statistically significant difference was detected among any of the the groups at T3 (P > 0.05). CONCLUSION: The use of materials that include both fluoride and chlorhexidine as routine treatment of children with disability may increase the success of restorations by improving oral hygiene, reduce the need for future restorative treatments and thus the need for general anaesthesia.

Premedication with midazolam prior to caesarean section has no neonatal adverse effects.

Like all surgical patients, obstetric patients also feel operative stress and anxiety. This can be prevented by giving patients detailed information about their operation and with preoperative pharmacological medications. Because of depressive effects of sedatives on newborns, pharmacological medications are omitted, especially in obstetric patients. The literature contains few studies concerning preoperative midazolam use in Caesarian section (C/S) patients. Our aim in this study was to help patients undergoing C/S surgery. One group scheduled for elective C/S received midazolam 0.025 mg kg(-1) intravenously, the other received saline. Maternal anxiety was evaluated using Amsterdam Preoperative Anxiety and Information Scale (APAIS) scores, and newborns were evaluated using Apgar and the Neonatal Neurologic and Adaptive Capacity Score (NACS). In conclusion, patients receiving midazolam 0.025 mg kg(-1) as premedication had significantly low anxiety scores, without any adverse effects on the newborns. Midazolam can therefore safely be used as a premedicative agent in C/S surgery.

A pré-medicação com midazolam antes de secção cesariana não tem efeitos adversos no neonato / Premedication with midazolam prior to caesarean section has no neonatal adverse effects / La premedicación con midazolam antes de la sección de cesárea no tiene efectos adversos en el neonato

Como todos os pacientes cirúrgicos, pacientes obstétricas também sentem estresse e ansieda de operatórios. Isso pode ser prevenido se forem passadas à paciente informações detalhadas sobre sua operação e se forem administrados medicamentos farmacológicos pré-operatórios. Devido aos efeitos depressivos dos sedativos nos neonatos, os medicamentos farmacológicos são omitidos, especialmente em pacientes obstétricas. A literatura contém poucos estudos concernentes ao uso de midazolam no pré-operatório em pacientes de secção cesariana (C/S). Nosso objetivo nesse estudo foi ajudar nossas pacientes passando por cirurgia C/S. Um grupo agendado para C/S eletiva recebeu midazolam 0,025 mg kg−1 por via intraveno sa; o outro grupo recebeu salina. A ansiedade materna foi avaliada com o uso dos escores da Amsterdam Preoperative Anxiety and Information Scale (APAIS) (Escala de Ansiedade e Informação Pré-operatória de Amsterdam), e os neonatos foram avaliados por Apgar e pelo instrumento Neonatal Neurologic and Adaptive Capacity Score (NACS) (Escore Neurológico e de Capacidade Adaptativa do Neonato). Em conclusão, os pacientes pré-medicados com midazolam 0,025 mg kg−1 medicação tiveram escores de ansiedade significativamente baixos, sem qualquer efeito adverso nos neonatos. Portanto, midazolam pode, com segurança, ser utilizado como agente de pré-medicação na cirurgia C/S.

Like all surgical patients, obstetric patients also feel operative stress and anxiety. This can be prevented by giving patients detailed information about their operation and with preoperative pharmacological medications. Because of depressive effects of sedatives on newborns, pharmacological medications are omitted, especially in obstetric patients. The literature contains few studies concerning preoperative midazolam use in Caesarian section (C/S) patients. Our aim in this study was to help patients undergoing C/S surgery. One group scheduled for elective C/S received midazolam 0.025 mg kg-1 intravenously, the other received saline. Maternal anxiety was evaluated using Amsterdam Preoperative Anxiety and Information Scale (APAIS) scores, and newborns were evaluated using Apgar and the Neonatal Neurologic and Adaptive Capacity Score (NACS). In conclusion, patients receiving midazolam 0.025 mg kg-1 as premedication had significantly low anxiety scores, without any adverse effects on the newborns. Midazolam can therefore safely be used as a premedicative agent in C/S surgery.

Como todos los pacientes quirúrgicos, las pacientes obstétricas también sienten estrés y ansiedad operatorios. Eso puede prevenirse si se le transmiten a la paciente informaciones detalladas sobre su operación y si se administran medicamentos farmacológicos preoperatorios. Debido a los efectos depresivos de los sedativos de los neonatos, los medicamentos farmacológicos se omiten, especialmente en pacientes obstétricas. La literatura contiene pocos estudios concernientes al uso de midazolam en el preoperatorio en pacientes de sección de cesárea (C/S). Nuestro objetivo en ese estudio, fue ayudar a nuestras pacientes pasando por una cirugía C/S. Un grupo con cita para C/S electiva recibió midazolam 0,025 mg.kg-1 por vía intravenosa; el otro grupo recibió salina. La ansiedad materna se evaluó con el uso de las puntuaciones de la Amsterdam Preoperative Anxiety and Information Scale (APAIS) (Escala de Ansiedad e Información Preoperatoria de Ámsterdam), y los neonatos se evaluaron por APGAR y porel instrumento Neonatal Neurologic and Adaptive Capacity Score (NACS) (Puntuación Neurológica y de Capacidad Adaptativa del Neonato). Como colofón, podemos decir que los pacientes premedicados con midazolam con 0,025 mg.kg-1 de medicación, alcanzaron puntuaciones de ansiedad significativamente bajas, sin ningún efecto adverso en los neonatos. Por tanto, el midazolam puede ser utilizado con seguridad como un agente de premedicación en la cirugía C/S.

Hematoma retrofaríngeo secundário a pequeno trauma contuso no pescoço: relato de caso / Retropharyngeal hematoma secondary to minor blunt neck trauma: case report / Hematoma retrofaríngeo secundario a un pequeño trauma contundente en el cuello: relato de caso

JUSTIFICATIVA E OBJETIVOS: O desenvolvimento de hematoma retrofaríngeo após trauma contuso é uma ocorrência rara. Porém, uma lesão ocupando espaço nessa área pode ser fatal, o que exige rápida avaliação e tratamento. Esse tipo de hematoma é clinicamente importante devido à proximidade entre o espaço retrofaríngeo e a via aérea superior. Qualquer edema nesse espaço pode causar uma protuberância da parede posterior da faringe de encontro às vias aéreas e obstruí-las. RELATO DE CASO: Paciente do sexo feminino, 86 anos, que caiu de uma altura de 1,5 m e bateu o pescoço na escada, foi admitida em nosso Departamento de Traumatologia. Tomografia computadorizada e radiografia dos tecidos moles do pescoço foram feitas e mostraram uma grande massa retrofaríngea que se estendia da base do crânio até o nível dos pulmões. A paciente ficou em observação e o tamanho do hematoma diminuiu espontaneamente nos sete dias subsequentes; contudo, devido a uma infecção pulmonar, a paciente foi a óbito no décimo dia. Este relato enfatiza que a drenagem precoce do hematoma retrofaríngeo poderia ter sido considerada neste caso. Embora seja de ocorrência rara, o hematoma retrofaríngeo é um problema que pode ser encontrado em serviços de emergência.

BACKGROUND AND OBJECTIVES: The development of a retropharyngeal hematoma following a blunt trauma is a rare occurrence. However, a spaceoccupying lesion in this area can be life-threatening and requires rapid assessment and treatment. This is clinically important because of the close proximity of the retropharyngeal space to the upper airway. Any swelling in the the posterior pharyngeal space may prompt it to bulge anteriorly into the airway and cause its obstruction. CASE REPORT: A 86-year-old woman fell from a height of 1.5 m and hit her neck on stairs and was admitted to our trauma department. A computerized tomography scan and a lateral neck x-ray to observe the soft tissue revealed a large retropharyngeal mass extending from the base of the skull down to the level of the lung. The patient was kept under observation and the hematoma reduced spontaneously in the following seven days although the patient died on the tenth day from pulmonary infection. The report emphasizes that early drainage of a retropharyngeal hematoma should be considered in similar cases. Although rarely encountered, retropharyngeal hematoma is a problem that can be faced in an emergency department.

JUSTIFICATIVA Y OBJETIVOS: El desarrollo del hematoma retrofaríngeo posterior al trauma contundente es un hecho raro. Sin embargo, una lesión que ocupa un espacio en esa área puede ser fatal, lo que exige una rápida evaluación y el tratamiento adecuado. Ese tipo de hematoma es clínicamente importante debido a la cercanía entre el espacio retrofaríngeo y la vía aérea superior. Cualquier hinchazón en ese espacio puede causar una protuberancia de la pared posterior de la faringe contra las vías aéreas y obstruirlas. RELATO DE CASO: Paciente del sexo femenino, de 86 años, que se cayó de una altura de 1,5 m y se dio con la escalera en el cuello. Fue admitida en nuestro Departamento de Traumatología. Se realizaron la tomografía computadorizada y la radiografía de los tejidos suaves del cuello, lo que arrojó una gran masa retrofaríngea que se extendía desde la base del cráneo hasta el nivel de los pulmones. La paciente permaneció en observación y el tamaño del hematoma se redujo espontáneamente en los siete días posteriores; sin embargo, y debido a una infección pulmonar, la paciente falleció al décimo día. Ese relato nos muestra que el drenaje rápido del hematoma retrofaríngeo podría haber sido considerado en ese caso. Y aunque sea de una baja incidencia, el hematoma retrofaríngeo es un problema que puede ser encontrado en los servicios de emergencia.

Retropharyngeal hematoma secondary to minor blunt neck trauma: case report.

BACKGROUND AND OBJECTIVES: The development of a retropharyngeal hematoma following a blunt trauma is a rare occurrence. However, a space-occupying lesion in this area can be life-threatening and requires rapid assessment and treatment. This is clinically important because of the close proximity of the retropharyngeal space to the upper airway. Any swelling in the the posterior pharyngeal space may prompt it to bulge anteriorly into the airway and cause its obstruction. CASE REPORT: A 86-year-old woman fell from a height of 1.5m and hit her neck on stairs and was admitted to our trauma department. A computerized tomography scan and a lateral neck x-ray to observe the soft tissue revealed a large retropharyngeal mass extending from the base of the skull down to the level of the lung. The patient was kept under observation and the hematoma reduced spontaneously in the following seven days although the patient died on the tenth day from pulmonary infection. The report emphasizes that early drainage of a retropharyngeal hematoma should be considered in similar cases. Although rarely encountered, retropharyngeal hematoma is a problem that can be faced in an emergency department.

Evaluation of sedation in oral and maxillofacial surgery in ambulatory patients: failure and complications.

OBJECTIVES: This study evaluated the failure and complication rates of sedation in ambulatory patients undergoing oral and maxillofacial surgery. MATERIALS AND METHODS: This retrospective cohort study was carried out among 619 patients who had undergone maxillofacial surgical procedures under intravenous sedation with midazolam and fentanyl. Each patient's age, American Society of Anesthesiologists (ASA) classification, systemic condition, surgical procedure, complications, and failures were recorded for evaluation. RESULTS: A total of 400 patients with ASA I, 199 with ASA II, and 20 with ASA III between the ages of 9 months and 84 years were included in the study. The most common systemic disorders in our patients were mental retardation (35%), hypertension (19%), and epilepsy (15%). Evaluation of the cases revealed 9 complications (1.4%) and 9 sedation failures (1.4%). The complications were bradycardia, postoperative agitation and hallucination, drug reaction, vomiting and nausea, desaturation, and hypotension. CONCLUSIONS: Our results in the oral and maxillofacial surgery clinic revealed low complication and failure rates.

A 3-year follow-up of the rehabilitation of Papillon-Lefèvre syndrome by dental implants.

PURPOSE: Papillon-Lefèvre syndrome is a rare autosomal recessive genetic disorder characterized by palmar-plantar hyperkeratosis, with rapidly progressive periodontitis and premature loss of both deciduous and permanent teeth. This article presents the prosthetic rehabilitation of a patient with Papillon-Lefèvre syndrome with dental implants. MATERIALS AND METHODS: Twelve titanium implants were installed in the mandible and maxilla in an 18-year-old male patient with Papillon-Lefèvre syndrome. RESULTS: At 3 years follow-up, all implants were clinically stable and no pain or infection was found. The patient continues to be seen at regular follow-up visits. CONCLUSION: Twelve-implant installation in Papillon-Lefèvre syndrome with 3 years' follow-up has not claimed before. We not only successfully treated our patient functionally and esthetically with dental implant rehabilitation, but also provided psychological benefits to the patient.

A Case of Escherichia coli Endocarditis After Hemorrhoidectomy Performed by a Herbalist.

We describe the first reported case of Escherichia coli endocarditis following a hemorrhoidectomy that was performed by the patient's herbalist. With increasing frequency, patients are seeking care by those who practice alternative medicine. Physicians must become more aware of the impact and possible complications related to this practice. Prosthetic valve endocarditis ranges up to 1.5% per patient-year for mechanical mitral valves and up to 0.1% per patient-year for other valves. Although the incidence of aortic prosthetic valve endocarditis is not uncommon, the concomitant organism and its mode of bacteremia make this a most unusual case. There is a paucity of information in the literature regarding surgical complications performed by alternative medicine practitioners. To our knowledge, a case of gram-negative endocarditis as a result of hemorrhoidectomy performed by an herbalist has never been reported.

Does propofol prevent testicular ischemia-reperfusion injury due to torsion in the long term?

OBJECTIVES: Our aim was to investigate the long-term preventive effect of propofol on testicular ischemia-reperfusion injury in a rat model. METHODS: Twenty-four adult male Sprague-Dawley rats were randomly divided into four groups (n = 6 for each group), control, sham-operated, torsion/detorsion (T/D) and T/D + propofol. Testicular ischemia was achieved by twisting the left testis 720° clockwise for 2 h. Half an hour before detorsion, 50 mg/kg propofol was given intraperitoneally to the T/D + propofol group. Ipsilateral orchiectomies to determine mean testicular weights and histopathological examination according to Johnsen's mean testicular biopsy score criteria were performed 30 days after surgical procedure in all groups. RESULTS: Mean testicular weights were 1.57 ± 0.12 g in group I, 1.59 ± 0.36 g in group II, 0.84 ± 0.20 g in group III and 0.87 ± 0.29 g in group IV. Mean testicular weights decreased significantly in the T/D groups, but no improvement in testicular weight was observed with propofol administration (p 0.9372). Similarly, the Johnsen's mean testicular biopsy scores of the T/D groups were lower than those of the control and sham-operated groups, but no positive effect was determined with the administration of propofol in the T/D groups (p 0.1797). CONCLUSIONS: Our results showed that there is no apparent long-term therapeutic potential attendant on using propofol in the treatment of testicular ischemia-reperfusion injury caused by testis torsion.

Evaluation of sedation failure in the outpatient oral and maxillofacial surgery clinic.

PURPOSE: Our goal was to report on the incidence of sedation failures in our outpatient oral surgery clinic. Sedation failure is the inability to complete a procedure under intravenous sedation. There is very little in the oral surgery literature on this subject. MATERIALS AND METHODS: Proper Institutional Review Board approval was obtained from the appropriate governing body for this project. The medical records of 539 intravenous sedation patients treated at the Oral and Maxillofacial Surgery Clinic at our institution were retrospectively evaluated to determine the incidence of failed sedation. Patients sedated with midazolam and fentanyl were placed in group A. There were 323 patients in group A. We placed patients sedated with midazolam, fentanyl and methohexital into group B. There were 216 patients in group B. The gender, medical history, type of procedure being performed, amount of drug given, and the patient's vital signs throughout the procedure were recorded. RESULTS: There were 9 failed sedations with a rate of 1.6% (9/539); 3 in group B (1%) and 6 in group A (2%). Five of our failures were undergoing multiple tooth extractions. Two of the failures were undergoing surgical removal of impacted third molars. Two patients underwent mandibular fracture reduction. Failure was attributed to increased agitation and combativeness, uncontrolled hypertension, tachycardia and desaturation. CONCLUSION: The mandible fracture population and multiple teeth extraction patients had higher rates of failure than other groups. This may be the result of procedure length, type of procedure, or a preoperative anxiety and attitude toward treatment expressed by the patient making sedation unpredictable. Level of training and experience of the practitioner may contribute to sedation failure. These results allow us to develop a prospective study protocol of outpatient sedation and to quantify more detailed information about preoperative anxiety, medical status, and social history than we had available during our chart review. More specific conclusions may help us determine if certain patient populations are at a higher risk for failed sedations.

A patient with Glanzmann's thrombasthenia for emergent abdominal surgery.

Glanzmann's thrombasthenia is a rare autosomal recessive disease characterized by potentially major mucocutaneous complications and nose bleeds. It is considered hazardous for these surgical patients to conceive, with a high risk of urgent surgery. The treatment of bleeding or prevention of hemorrhage for surgery or invasive procedures is based on platelet transfusion. However, platelet transfusions may be responsible for the development of alloimmunization, with a high risk of future platelet refractoriness. We report a surgical case of Glanzmann's thrombasthenia complicated by nasopharyngeal bleeding and managed with platelet transfusions, recombinant activated factor VII, and postoperative airway management in the intensive care unit.