Factors Influencing Pre-Cardiopulmonary Arrest Signs among Post-General Surgery Patients in Critical Care Service System.

Health service system factors can lead to pre-cardiopulmonary arrest signs (pre-CA), which refer to a critical condition in the body leading to a circulatory and respiratory system disruption. The purpose of this study was to assess the incidence rate of an event leading to pre-cardiopulmonary arrest signs within the first 24 h, and also to analyze the factors influencing the health service system in critical post-general surgery patients in the intensive care unit. These results of the study found the incidence rate of pre-CA was 49.05 per 1000 person-hours, especially 1 h after admission to the ICU. Hemodynamic instability, respiratory instability, and neurological alteration were the most common pre-CA symptoms. The patient factors associated with high pre-CA arrest sign scores were the age from 18-40 years, with an operation status as emergency surgery, elective surgery compared with urgent surgery, and the interaction of operation status and age in critical post-general surgery patients. The organization factors found advanced hospital level and nurse allocation were associated with pre-CA. To improve quality of care for critical post-general surgery patients, critical care service delivery should be delegated to nurses with nurse allocation and critical care nursing training. Guidelines must be established for critically ill post-general surgery patient care.

H1 and H2 antihistamines pretreatment for attenuation of protamine reactions after cardiopulmonary bypass: a randomized-controlled study.

BACKGROUND: Protamine administration post-cardiopulmonary bypass (CPB) can potentially cause hemodynamic instability. Histamine released from mast cells is believed to be responsible for hypotension after protamine administration. The aim of this study was to examine the effects of pretreatment with H1 and H2 antihistamines on changes in systemic arterial pressure following protamine administration. METHODS: This study was a randomized, triple-blinded, placebo-controlled study, conducted at a university hospital. Forty adult patients undergoing elective coronary artery bypass grafting (CABG) or single valve surgery were included. The patients were randomly allocated (20 patients in each group) to receive a single dose of combined chlorpheniramine 10 mg and ranitidine 50 mg or normal saline intravenously immediately after separation from CPB prior to protamine administration. Trajectory changes in systolic blood pressure (SBP), mean arterial pressure (MAP), and vasoactive-inotropic score (VIS) from baseline until 35 minutes following protamine administration (24-time points) were compared between the two groups. Serial serum tryptase levels were also obtained at baseline, 30 and 60 minutes after protamine was given. RESULTS: Forty patients were included in the analysis. Demographic and baseline blood pressure were similar between the two groups. At 30 minutes after protamine administration, there were no significant differences in both crude SBP [mean difference: -7.1 mmHg, 95% confidence interval (CI), -1.1 to 15.3 mmHg, P=0.09] and SBP after adjustment for the European System for Cardiac Operative Risk Evaluation (EuroSCORE II), CPB time, and VIS (mean difference: -3.9 mmHg, 95% CI, -11.9 to 4.0 mmHg, P=0.33). There were also no significant differences in crude MAP (mean difference: -2.1 mmHg, 95% CI, -6.9 to 2.7 mmHg, P=0.39) and adjusted MAP (mean difference: -0.7 mmHg, -5.9 to 4.4 mmHg, P=0.78) between the two groups. None of the patients in both groups had a significant increase in serum tryptase from baseline. No differences in median serum tryptase levels at baseline, 30 and 60 minutes were demonstrated between the two groups. CONCLUSIONS: Pretreatment with H1 and H2 antihistamines does not attenuate blood pressure responses to protamine administration in patients after CPB. Mechanisms other than histamine release from mast cells might be responsible for protamine-induced cardiovascular changes. TRIAL REGISTRATION: ClinicalTrials.gov NCT03583567.

Lung ultrasound is non-inferior to bronchoscopy for confirmation of double-lumen endotracheal tube positioning: a randomized controlled noninferiority study.

BACKGROUND: Appropriate placement of left-sided double-lumen endotracheal tubes (LDLTs) is paramount for optimal visualization of the operative field during thoracic surgeries that require single lung ventilation. Appropriate placement of LDLTs is therefore confirmed with fiberoptic bronchoscopy (FOB) rather than clinical assessment alone. Recent studies have demonstrated lung ultrasound (US) is superior to clinical assessment alone for confirming placement of LDLT, but no large trials have compared US to the gold standard of FOB. This noninferiority trial was devised to compare lung US with FOB for LDLT positioning and achievement of lung collapse for operative exposure. METHODS: This randomized, controlled, double-blind, noninferiority trial was conducted at the Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand from October 2017 to July 2019. The study enrolled 200 ASA classification 1-3 patients that were scheduled for elective thoracic surgery requiring placement of LDLT. Study patients were randomized into either the FOB group or the lung US group after initial blind placement of LDLT. Five patients were excluded due to protocol deviation. In the FOB group (n = 98), fiberoptic bronchoscopy was used to confirm lung collapse due to proper positioning of the LDLT, and to adjust the tube if necessary. In the US group (n = 97), lung ultrasonography of four pre-specified zones (upper and lower posterior and mid-axillary) was used to assess lung collapse and guide adjustment of the tube if necessary. The primary outcome was presence of adequate lung collapse as determined by visual grading by the attending surgeon on scale from 1 to 4. Secondary outcomes included the time needed to adjust and confirm lung collapse, the time from finishing LDLT positioning to the grading of lung collapse, and intraoperative parameters such has hypotension or hypertension, hypoxia, and hypercarbia. The patient, attending anesthesiologist, and attending thoracic surgeon were all blinded to the intervention arm. RESULTS: The primary outcome of lung collapse by visual grading was similar between the intervention and the control groups, with 89 patients (91.8%) in the US group compared to 83 patients (84.1%) in the FOB group (p = 0.18) experiencing adequate collapse. This met criteria for noninferiority per protocol analysis. The median time needed to confirm and adjust LDLT position in the US group was 3 min (IQR 2-5), which was significantly shorter than the median time needed to perform the task in the FOB group (6 min, IQR 4-10) (p = 0.002). CONCLUSIONS: In selected patients undergoing thoracic surgery requiring LDLT, lung ultrasonography was noninferior to fiberoptic bronchoscopy in achieving adequate lung collapse and reaches the desired outcome in less time. TRIAL REGISTRATION: This study was registered at clinicaltrials.gov, NCT03314519 , Principal investigator: Kasana Raksamani, Date of registration: 19/10/2017.

Low dose intraoperative ketamine infusion with multilevel paravertebral block for pain after video-assisted thoracic surgery: a randomized-controlled study.

BACKGROUND: Intraoperative low-dose ketamine infusion has been reported to be an effective adjuvant to opioids for postoperative pain control without major side effects, but it has not been tested in video-assisted thoracic surgery (VATS). The aim of this study was to examine the effect of low-dose intraoperative intravenous ketamine infusion on 24-hour morphine requirement and acute postoperative pain following VATS for lung resection. METHODS: This study was a single center, randomized, double-blind, placebo-controlled study. Thirty-two patients undergoing elective VATS for lung resection in a university hospital were included. Patients were randomly allocated (1:1 ratio) to receive either intraoperative low-dose ketamine (0.2 mg/kg/h) or normal saline infusion starting from intubation to the beginning of chest closure. All patients received multilevel thoracic paravertebral block (TPVB) and morphine was administered postoperatively via the patient-controlled analgesia pump using the same protocol. Time to first analgesia, postoperative cumulative morphine doses at 10, 30 minutes, and the consecutive 1, 2, 6, 12, 18, and 24 hours were recorded. Pain intensity during rest and deep breathing were also assessed by numeric rating scale (NRS) score at 1- and 24-hour postoperatively. RESULTS: There was no significant difference in median (P25, P75) cumulative 24-hour morphine requirement between the ketamine and the control groups [15 (5.5, 29.5) vs. 22.5 (15.3, 40.8) mg, P=0.090]. Patients in ketamine group had significantly longer median pain free time than the control group (27 vs. 2 minutes, P=0.006). No difference in overall NRS score at rest or during deep breathing at 1- and 24-hour postoperatively was demonstrated (P=0.861). CONCLUSIONS: Intraoperative low dose ketamine infusion in addition to TPVB does not reduce postoperative morphine consumption or pain intensity but may prolong pain free time in patients undergoing VATS for lung resection.

Propofol with or without fentanyl for pain relief after transrectal ultrasound-guided prostate (TRUS-P) biopsy: a randomized controlled study.

BACKGROUND: Postoperative pain from transrectal ultrasound-guided prostate (TRUS-P) biopsy under sedation is often mild. Benefit of opioids used during sedation is controversial. OBJECTIVE: The objective was to compare numeric rating scale (NRS) score at 30 minutes after TRUS-P biopsy between patients receiving propofol alone or with fentanyl. METHODS: We randomly allocated 124 patients undergoing TRUS-P biopsy to receive either fentanyl 0.5 mcg.kg-1 (Group F) or normal saline (Group C). Both groups received titrated propofol sedation via Target-controlled infusion (TCI) with Schneider model until the Observer's Assessment of Alertness/Sedation (OAA/S) scale 0-1 was achieved. Hemodynamic variables, patient movement, postoperative pain score, patient and surgeon satisfaction score were recorded. RESULTS: Overall, most patients (97.5%) had no to mild pain. Group F had significantly lower median NRS score at 30 minutes compared to Group C (0 [0, 0] vs. 0 [0, 0.25], p = 0.039). More patients in Group C experienced pain (90% vs. 75.8%, p =  0.038). Perioperative hypotension was higher in group F (81.7%) compared to Group C (61.3%) (p =  0.013). Thirty-five (56.5%) patients in Group F and 25 (42.7%) patients in Group C had movement during the procedure (p = 0.240). Surgeon's satisfaction score was higher in Group F (10 [9, 10]) than Group C (9 [9, 10]) (p =  0.037). CONCLUSION: Combining low dose fentanyl with TCI propofol sedation may provide additional benefit on postoperative pain after TRUS-P biopsy, but results in perioperative hypotension. Fentanyl may attenuate patient movement during the procedure, which leads to greater surgeon's satisfaction.

Comparison of High-Flow Humidified Oxygen With Conventional Continuous Positive Airway Pressure in Nonventilated Lungs During Thoracic Surgery: A Randomized Cross-Over Study.

OBJECTIVE: This study assessed the efficacy of high-flow humidified oxygen (HFHO) as an alternative to continuous positive airway pressure (CPAP) for improving oxygenation while preserving nonventilated lung collapse during one-lung ventilation. DESIGN: A prospective randomized cross-over trial. SETTING: A tertiary medical center. PARTICIPANTS: The study comprised 28 patients undergoing elective thoracotomy with one-lung ventilation using a double-lumen endobronchial tube placement. INTERVENTIONS: The patients received prophylactic CPAP or HFHO to the nonventilated lung for 20 minutes and were then crossedover to the other oxygenation modality for 20 minutes, with a 20-minute recovery interval between the two modalities. MEASUREMENTS AND MAIN RESULTS: Changes in respiratory parameters and lung deflation quality were recorded. Both CPAP and HFHO increased the partial pressure of arterial oxygen in either sequence in both groups, ranging from 31.8-to-66.0 mmHg. However, the increments from these two interventions were not statistically significant (95% confidence interval -12.84 to 21.87; p = 0.597). There were no differences in other parameters. Half the patients receiving CPAP experienced worsening of the surgical condition, whereas the HFHO patients experienced no change or reported a better lung deflation (p < 0.001). CONCLUSION: HFHO could be an alternative method to CPAP for improving arterial oxygenation while preserving lung deflation during one-lung ventilation. However, additional studies are warranted in regard to its cost-effectiveness and establishment as a routine treatment.

Regional Catheters for Postoperative Pain Control: Review and Observational Data.

CONTEXT: Perioperative analgesia is an essential but frequently underrated component of medical care. The purpose of this work is to describe the actual situation of surgical patients focusing on effective pain control by discarding prejudice against 'aggressive' measures. EVIDENCE ACQUISITION: This is a narrative review about continuous regional pain therapy with catheters in the postoperative period. Included are the most-relevant literature as well as own experiences. RESULTS: As evidenced by an abundance of studies, continuous regional/neuraxial blocks are the most effective approach for relief of severe postoperative pain. Catheters have to be placed in adequate anatomical positions and meticulously maintained as long as they remain in situ. Peripheral catheters in interscalene, femoral, and sciatic positions are effective in patients with surgery of upper and lower limbs. Epidural catheters are effective in abdominal and thoracic surgery, birth pain, and artery occlusive disease, whereas paravertebral analgesia may be beneficial in patients with unilateral approach of the truncus. However, failure rates are high, especially for epidural catheter analgesia. Unfortunately, many reports lack a comprehensive description of catheter application, management, failure rates and complications and thus cannot be compared with each other. CONCLUSIONS: Effective control of postoperative pain is possible by the application of regional/neuraxial catheters, measures requiring dedication, skill, effort, and funds. Standard operating procedures contribute to minimizing complications and adverse side effects. Nevertheless, these methods are still not widely accepted by therapists, although more than 50% of postoperative patients suffer from 'moderate, severe or worst' pain.

Awareness about radiation hazards and knowledge about radiation protection among healthcare personnel: A quaternary care academic center-based study.

BACKGROUND: The use of medical radiation in diagnosis and procedural and surgical treatment is increasing. Therefore, healthcare personnel should be adequately aware and knowledgeable about radiation hazards to protect themselves and their patients from its adverse effects. The objective of this study was to examine awareness about radiation hazards and knowledge about protection methods among the anesthesia personnel and surgical subspecialists of a quaternary care academic center. METHODS: A validated questionnaire was completed by anesthetic personnel and surgical subspecialists. It consisted of questions that required demographic information and assessed awareness about radiation hazards. In addition, 15 multiple-choice questions assessed knowledge about radiation across the following domains: the main principle of radiation protection, personal annual radiation dose, personal protection equipment, safe distance from an X-ray machine, and susceptible organs. RESULTS: A total of 270 potential participants were emailed and invited to respond to an online questionnaire, and the response rate was 79.3%. Of the 214 participants, 69.2% were women; the mean age of the sample was 34.8 years. Most of the participants (63.1%) considered radiation exposure that occurs as a part of daily work to be very harmful; 86.4% and 78.5% reported that they always wore a lead apron and a thyroid shield when working in an environment that entails radiation exposure, respectively. The mean score for knowledge about radiation hazards and protection was 6.4 ± 2.0 (maximum possible score = 15) Therefore, there is a need to improve anesthetic personnel and surgical subspecialists' knowledge about radiation protection, especially with regard to the use of lead goggles and harmful doses of radiation. CONCLUSION: The present findings suggest that there is a reasonable level of awareness but a relative lack of knowledge about radiation hazards and protection among anesthesia personnel and surgical subspecialists. Therefore, continuing medical education on radiation hazards and protection must be mandated.

Allogeneic red cell transfusion and its influence on relevant humoral and cellular immunological parameters: A prospective observational trial.

BACKGROUND: It is assumed that transfusion of allogeneic red cells is associated with increased peri-operative mortality and morbidity. Also assumed is the theory of transfusion-related immunomodulation. OBJECTIVE: The aim of this study was to investigate the hypothesis that red cell transfusion specifically leads to an immunological response in surgical patients. DESIGN: Prospective observational study. SETTING: Departments of Orthopedic Surgery and Anaesthesia, University Hospital, Thailand. PATIENTS: Low-risk, noncancer patients, aged 18 to 75 years undergoing elective major spine surgery, with and without red cell transfusion therapy. INTERVENTIONS: Blood specimens were withdrawn four times (prior to surgery and on days 1, 3 and 5). MAIN OUTCOME MEASURES: Assessment of immunocompetent cells and cytokines in transfused and nontransfused patients using flow cytometry and multiplex ELISA. RESULTS: From a total of 78 patients, 61 met the requirements and were analysed in three groups: 19 with no transfusion and 26 and 16 transfused intra-operatively and on day 1 or 2, respectively. No patient experienced peri-operative haemorrhage. Postoperative infection or thrombosis occurred in 5.5% of nontransfused patients and 16.6% of transfused patients; the difference was not significant. There was no significant immunomodulatory effect of red cell transfusion: of 45 immunological parameters, only five little-relevant cytokines were significantly affected, although slightly and nonspecifically. CONCLUSION: Our data indicate that red cell transfusion alone does not create an immunological response in otherwise healthy surgical patients. Our findings do not generally contradict the transfusion-related immunomodulation phenomenon, which has, however, primarily been observed in patients with an already weakened or procedure-deteriorated immune system, such as from malignant disease, significant comorbidity, extensive abdominal/thoracic surgery and cardiopulmonary bypass. TRIAL REGISTRATION: The study was registered on 15 May 2014, before enrolment of the first patient, at www.ClinicalTrials.gov, NCT02140216.

A rare case of acute kidney injury and anemia induced by hypercalcemia.

Hypercalcemia may result in acute kidney injury (AKI) and arterial hypertension. Anemia as a consequence of this constellation is nowhere described. A female patient underwent total thyroidectomy in 2007, since then being under continuous daily medication with 100 µg thyroxin, 1.6 g calcium and 1.0 µg alfacalcidol. In 2017, after accidentally overdosing alfacalcidol fourfold for several weeks leading to massive hypercalcemia (plasma calcium level 16.7 mg/dL), the otherwise healthy patient developed symptoms of AKI, such as serum creatinine 2.48 mg/dL, plus severe hypertension and acute anemia (hemoglobin concentration 10.2 g/dL). After cessation of calcium and alfacalcidol medication for 9 days, hypercalcemia and AKI symptoms and anemia recovered within 14 and after 62 days, respectively. The patient is currently free of complaints and has been sufficiently treated with half of the yearslong pre-event calcium/alfacalcidol dose. In conclusion, hypercalcemia with consecutive AKI after vitamin D overdose can occur asymptomatically. The treatment does not compulsorily include washout by hyperhydration and diuretics. AKI may lead to anemia, possibly caused by the deterioration of the release of erythropoietin.

Dorsal Longitudinal T-Myelotomy (Bischof II Technique): A Useful, Antiquated Procedure for the Treatment of Intractable Spastic Paraplegia.

OBJECTIVE: Dorsal longitudinal T-myelotomy is a long-established operation to treat severe spastic paraplegia. The present study aimed to report this surgical technique and investigate the efficacy of T-myelotomy for spasticity relief. METHODS: All cases undergoing T-myelotomy for treatment of intractable spastic paraplegia during 2009-2017 were included. The severity of spasticity was evaluated with the Modified Ashworth Scale, Penn Spasm Frequency Scale, Adductor Tone Rating Scale, degree of passive range of motion, and occurrence of abdominal muscle spasms. Other clinical assessments included deep tendon reflex assessed by the National Institute of Neurological Disorders and Stroke scale, Babinski sign, healing of decubitus ulcers, and ambulatory status. RESULTS: Fourteen patients with a mean age of 39.3 ± 13.4 years were included. The 7 patients with abdominal muscle spasms before surgery had no spasms after surgery. The Babinski sign was absent in all cases after surgery. Unhealed pressure ulcers in all 9 cases were healed after surgery. All 4 patients with a preoperative bed-bound condition were able to ambulate with a wheelchair. A statistically significant improvement in mean Modified Ashworth Scale score, degree of passive range of motion, and National Institute of Neurological Disorders and Stroke scale score was found in the subgroup and overall analyses. There was also a statistically significant improvement in the Penn Spasm Frequency Scale and Adductor Tone Rating Scale scores. CONCLUSIONS: Dorsal longitudinal T-myelotomy remains an effective option for the treatment of intractable spastic paraplegia. It is suitable for, and may be an alternative to, intrathecal baclofen therapy for patients with complete spinal cord lesion or patients without hope of regaining motor function.

Comparison of efficacy between dorsal root entry zone lesioning and selective dorsal rhizotomy for spasticity of cerebral origin.

BACKGROUND: Severe spasticity adversely affects patient functional status and caregiving. No previous study has compared efficacy between dorsal root entry zone lesioning (DREZL) and selective dorsal rhizotomy (SDR) for reduction of spasticity. This study aimed to investigate the efficacy of DREZL and SDR for attenuating spasticity, and to compare efficacy between these two methods. METHODS: All patients who underwent DREZL, SDR, or both for treatment of intractable spasticity caused by cerebral pathology at Siriraj Hospital during 2009 to 2016 were recruited. Severity of spasticity was assessed using Modified Ashworth Scale (MAS) and Adductor Tone Rating Scale (ATRS). Ambulatory status was also evaluated. RESULTS: Fifteen patients (13 males) with a mean age of 30.3 ± 17.5 years were included. Eight, six, and one patient underwent DREZL, SDR, and combined cervical DREZL and lumbosacral SDR, respectively. Eight of ten patients with preoperative bed-bound status had postoperative improvement in ambulatory status. Spasticity was significantly reduced in the DREZL group (p < 0.001), the SDR group (p < 0.001), and in overall analysis (p < 0.001). SDR was effective in both pediatric and adult spasticity patients. A significantly greater reduction in spasticity as assessed by MAS score (p < 0.001) and ATRS score (p = 0.015) was found in the DREZL group. Transient lower limb weakness was found in a patient who underwent SDR. CONCLUSIONS: DREZL is more effective for reducing spasticity, but is more destructive than SDR. DREZL should be preferred for bed-ridden patients, and SDR for ambulatory patients. Both operations are helpful for improving ambulatory status. Gait improvement was observed only in patients who underwent SDR. Adult patients with spasticity of cerebral origin benefit from SDR.

The therapeutic effects of ablative neurosurgical procedures on the spinal cord for intractable spinal spasticity.

STUDY DESIGN: This research is a retrospective study. OBJECTIVE: To study the therapeutic effects of operative procedures, including dorsal longitudinal myelotomy (DLM) and dorsal root entry zone lesion (DREZL) on spasticity and associated aspects. SETTING: Tertiary university hospital in Bangkok, Thailand. METHODS: Eighteen patients with refractory spasticity of spinal origin who underwent the operations were recruited. Clinical parameters for evaluating severity of spasticity and ambulatory status were compared between before and after surgery, and between surgeries. RESULTS: A statistically significant reduction of spasticity as measured by the Modified Ashworth Scale (MAS), Adductor Tone Rating Scale (ATRS) and Penn Spasm Frequency Scale (PSFS) was found after surgeries and in the overall analysis (p < 0.05). Chronic pressure ulcers disappeared postoperatively in 11 cases. All of 7 bed-ridden subjects experienced improvement in their ambulatory status postoperatively. DLM was found to be more effective than DREZL in reduction of spasticity. CONCLUSION: Ablative neurosurgery on the spinal cord is still valuable in situations when intrathecal baclofen is unavailable. These operations are potentially effective in the treatment of intractable spasticity of spinal origin.

Pain after Major Craniotomy in a University Hospital: A Prospective Cohort Study.

BACKGROUND: Pain after major craniotomy has been believed to be less severe than the other operations. OBJECTIVE: To determine the incidence and risk factors of moderate to severe pain after major craniotomy. MATERIAL AND METHOD: This is a prospective observational study in a neurosurgical intensive care unit and wards of a university, tertiary hospital. After institutional IRB approval, patients undergoing major craniotomy during May 2011-August 2012 were interviewed preoperatively and 24 and 48 hours postoperatively. Demographic data, preoperative anxiety scores, operative data and postoperative pain characteristics were recorded. RESULTS: Two hundred and eighty patients completed the study. The incidence of moderate to severe pain was 75%. Mean pain score during 24 and 48 hours were 5.5 ± 2.7 and 3.5 ± 2.6, respectively. Univariate analysis identified age under 45 years and perioperative steroid therapy as predictors of moderate to severe postoperative pain. Using multivariate analysis, only age under 45 years was a significant risk factor. Patients' satisfaction scores were good in both mild and moderate to severe pain groups (9.49 ± 1.08 and 8.37 ± 1.76). During postoperative period, almost all of the patients received intravenous opioid and oral acetaminophen for pain treatment. No respiratory depression occurred, but postoperative nausea and vomiting occurred in 51.7% and pruritus in 23.6%. CONCLUSION: Incidence of pain after craniotomy was high especially in younger age group, which is not in accordance with all similar reports. However we believe pain management after major craniotomy in our hospital requires improvement.

The uses of laryngeal mask airway ProSeal™ and endobronchial blocker for one lung anesthesia.

PURPOSE: The use of an endobronchial blocker in conjunction with a supraglottic device in elective thoracic cases has never been studied. The aim of this study was to report the success rate and time to placement of the endobronchial blocker in anaesthetized patients with a laryngeal mask airway (LMA)-ProSeal™ in place. METHODS: This was a single-center, prospective, descriptive pilot study that enrolled 30 patients aged 18-75 years, with ASA I-III, who underwent elective thoracotomy or video-assisted thoracoscopy. We collected data on time to placement of the endobronchial blocker into the selected bronchus, time consumed for final blocker positioning and inflation, lung deflation score at chest opening, and postoperative airway complications. RESULTS: One patient was excluded because of high peak airway pressure during LMA ventilation. The time required for blocker placement in the right main bronchus was shorter [mean 160 (78-480) s] compared with that for the left main bronchus [225 (117-420) s]. The blocker was successfully placed on the first attempt in 25 patients. Lung deflation score graded by the surgeon was 8/10 (median). Minor postoperative airway complications, such as sore throat (28.6 %) and hoarseness of voice (17.9 %), were reported. CONCLUSIONS: The use of LMA-ProSeal™ in conjunction with the COOPDECH Endobronchial Blocker Tube may be considered an alternative one-lung ventilation technique in selected cases. However, success rates and time required for placement of the blocker seem dependent on the operator's skill. Although postoperative sore throat and hoarseness of voice were reported, these improved in 24 h.

"Don juan-fracture" as a hint to aortic isthmus rupture.

We report a case of thoracic aortic rupture after blunt trauma in a 23-year-old male patient. The initial investigation found no external injury or bleeding, only a slightly widened mediastinum and a broken left calcaneus. Abdominal lavage was negative, biochemistry was normal, and breathing and oxygenation were not compromised. When changing his position during diagnostics, the patient all of a sudden developed cardiac arrest and typical signs of hypovolemic shock. An immediate sternotomy was done without any further diagnostics on suspicion of aortic isthmus injury. A circular avulsion at the ligamentum arteriosum was found as assumed and repaired under cardiopulmonary bypass. The patient left the hospital for rehabilitation after 12 days in adequate health status. Biodynamics of blunt trauma after high-speed frontal impact and the relationship between calcaneus fracture, called "Don-Juan fracture," and aortic rupture at the site of ligamentum arteriosum are discussed.

Pure oxygen ventilation during general anaesthesia does not result in increased postoperative respiratory morbidity but decreases surgical site infection. An observational clinical study.

Background. Pure oxygen ventilation during anaesthesia is debatable, as it may lead to development of atelectasis. Rationale of the study was to demonstrate the harmlessness of ventilation with pure oxygen. Methods. This is a single-centre, one-department observational trial. Prospectively collected routine-data of 76,784 patients undergoing general, gynaecological, orthopaedic, and vascular surgery during 1995-2009 were retrospectively analysed. Postoperative hypoxia, unplanned ICU-admission, surgical site infection (SSI), postoperative nausea and vomiting (PONV), and hospital mortality were continuously recorded. During 1996 the anaesthetic ventilation for all patients was changed from 30% oxygen plus 70% nitrous oxide to 100% oxygen in low-flow mode. Therefore, in order to minimize the potential of confounding due to a variety of treatments being used, we directly compared years 1995 (30% oxygen) and 1997 (100%), whereas the period 1998 to 2009 is simply described. Results. Comparing 1995 to 1997 pure oxygen ventilation led to a decreased incidence of postoperative hypoxic events (4.3 to 3.0%; p < 0.0001) and hospital mortality (2.1 to 1.6%; p = 0.088) as well as SSI (8.0 to 5.0%; p < 0.0001) and PONV (21.6 to 17.5%; p < 0.0001). There was no effect on unplanned ICU-admission (1.1 to 0.9; p = 0.18). Conclusions. The observed effects may be partly due to pure oxygen ventilation, abandonment of nitrous oxide, and application of low-flow anesthesia. Pure oxygen ventilation during general anaesthesia is harmless, as long as certain standards are adhered to. It makes anaesthesia simpler and safer and may reduce clinical morbidity, such as postoperative hypoxia and surgical site infection.