Closure vs non-closure of peritoneum at caesarean section: evaluation of pain.

We evaluated the effect of closure or non-closure of parietal and visceral peritoneum during caesarean section (CS) on post-caesarean pain and analgesic requirement. A total of 94 primigravidas planned for elective CS were prospectively enrolled into closure (n = 46) and non-closure (n = 48) groups. Analgesia was provided by a patient-controlled analgesia pump (PCA) postoperatively. Pain was evaluated using a visual analogue scale (VAS) and verbal rating scale (VRS). Total dose of analgesics administered through PCA and times of analgesia demand and additional analgesics were also assessed. VAS and VRS scores were similar between the groups. The total dose of analgesics administered were similar (p = 0.095) between groups, however the mean number of analgesic demand (p = 0.020) and the additional analgesics (p < 0.001) were higher in the closure group. As a conclusion, the closure or non-closure of the peritoneum does not have any impact on postoperative pain intensity, however the analgesia demand and additional analgesia requirement decreases with non-closure.

First pulmonary valve replacement with Freedom Solo stentless valve in an adolescent. A case report.

Tetralogy of Fallot (TOF) is a common form of cyanotic heart disease. Complete surgical correction in younger age group offers good long-term results with reasonable morbidity and improved prognosis in patients with TOF. However, following corrective surgery pulmonary valve replacement (PVR) might be required for residual pulmonary regurgitation in order to avoid irreversible right ventricular remodeling. Otherwise, residual uncorrected pulmonary regurgitation may lead to right ventricular dilatation, impaired biventricular function, ventricular arrhythmias and limited exercise capacity. We report the first case of Freedom Solo stentless valve (Sorin Group, Saluggia, Italy) implantation in the pulmonary position in an adolescent with severe pulmonary insufficiency 12 years after the repair of TOF. Pericardial stentless valves may be an alternative choice for pulmonary valve replacement to improve right ventricular contractile recovery and remodeling after PVR and may have impact on long-term survival.

Comparison of bupivacaine 0.2% and ropivacaine 0.2% combined with fentanyl for epidural analgesia during labour.

BACKGROUND AND OBJECTIVE: Recent clinical studies comparing ropivacaine 0.25% with bupivacaine 0.25% reported not only comparable analgesia, but also comparable motor block for epidural analgesia during labour. An opioid can be combined with local anaesthetic to reduce the incidence of side-effects and to improve analgesia for the relief of labour pain. The purpose of the study was to evaluate the effects of epidural bupivacaine 0.2% compared with ropivacaine 0.2% combined with fentanyl for the initiation and maintenance of analgesia during labour and delivery. METHODS: Sixty labouring nulliparous women were randomly allocated to receive either bupivacaine 0.2% with fentanyl 2 microg mL(-1) (B/F), or ropivacaine 0.2% with fentanyl 2 microg mL(-1) (R/F). For the initiation of epidural analgesia, 8 mL of the study solution was administered. Supplemental analgesia was obtained with 4 mL of the study solution according to parturients' needs when their pain was > or = 4 on a visual analogue scale. Analgesia, hourly local anaesthetic use, motor block, patient satisfaction and side-effects between groups were evaluated during labour and at delivery. RESULTS: Sixty patients were enrolled and 53 completed the study. No differences in verbal pain scores, hourly local anaesthetic use or patient satisfaction between groups were observed. However, motor block was observed in 10 patients in the B/F group whereas only two patients had motor block in the R/F group (P < 0.05). The incidence of instrumental delivery was also higher in the B/F group than in the R/F group (P < 0.05). CONCLUSIONS: The results suggest that epidural bupivacaine 0.2% and ropivacaine 0.2% combined with fentanyl produced equivalent analgesia for pain relief during labour and delivery. It is concluded that ropivacaine 0.2% combined with fentanyl 2 microg mL(-1) provided effective analgesia with significantly less motor block and need for an instrumental delivery than a bupivacaine/fentanyl combination at the same concentrations during labour and delivery.

Effects of combined conventional and modified ultrafiltration in adult patients.

BACKGROUND: Modified ultrafiltration (MUF) improves hemodynamics and postoperative recovery in children. Ultrafiltration (UF) may have similar benefits in adults. The purpose of this study was to investigate the effects of UF in adult patients. METHODS: A total of 40 adult patients undergoing cardiac surgery were randomized into a study group of conventional UF during bypass + venovenous MUF after bypass and a control group with no UF. Perioperative clinical variables, cytokines, and endothelin-1 levels were compared between groups. RESULTS: There was no mortality in either group. The patients in the study group had a greater rise in hematocrit (5.7% +/- 2.4% vs 1.2% +/- 1.9%, p < 0.001), hemoglobin (1.7 +/- 0.8 mg/mL vs 0.5 +/- 0.6 mg/mL, p < 0.0005), and platelet levels (27,800 +/- 29,200 vs -9,000 +/- 30,970, p < 0.001). Mean arterial blood pressure and CI increased after MUF (from 64.2 +/- 16.9 mm Hg to 72.3 +/- 14.1 mm Hg, p = 0.05, and from 2.4 +/- 0.7 to 2.8 +/- 0.6, p < 0.03, respectively). Postoperative oxygenation was better in the study group (alveolo-arterial PO2 tension gradient 74.6 +/- 43.9 mm Hg vs 107.2 +/- 27.8 mm Hg, p = 0.03). Ultrafiltration reduced postoperative bleeding (522.2 +/- 233.4 mL vs 740 +/- 198.4 mL, p < 0.003). CONCLUSIONS: A combination of conventional and modified UF is effective and safe in adult patients undergoing cardiac surgery. Ultrafiltration improved hemodynamics, hemostatic, and pulmonary functions. We recommend the use of combined UF in high-risk adult patients.

Recurrent pericardial effusion due to gunshot wound of the heart in a hemodynamically stable child--a case report.

A 12-year-old girl presented with recurrent pericardial effusion due to firearm pellet injury to the left ventricle. The pellet was localized by two-dimensional echocardiography within the left ventricular apical wall. Since the patient was asymptomatic, left ventriculotomy was avoided to extract the pellet and only pericardial tube drainage was carried out. A slightly elevated blood lead level of the patient was alarming for potential subsequent lead poisoning due to retained pellets.

Use of the laryngeal mask airway during ophthalmic surgery results in stable circulation and few complications: a prospective audit.

BACKGROUND: This study was performed to investigate airway complications related to Laryngeal Mask Airway (LMA) use in a selected group of paediatric patients undergoing ophthalmic surgery. METHODS: Ninety-four paediatric patients were enrolled. LMA was inserted under deep general anaesthesia with the standard technique previously described by Brain. Complications during induction, insertion of the LMA, maintenance of anaesthesia, removal of the LMA, emergence and on the first postoperative day were recorded. Failure of insertion, desaturation, laryngospasm, bronchospasm, vomiting, bucking, dislocation of the LMA, breath-holding, and coughing were noted. RESULTS: There was no significant age-related difference in successful insertion ratio of the LMA. In two patients (2%), the LMA could not be inserted with three attempts and tracheal intubation was performed. Laryngospasm was recorded in three patients (3%), leading to desaturation in two patients (SaO2 < 95%) during insertion of the LMA. During maintenance of anaesthesia bucking occurred in one patient (1%). After removal of the LMA, incidence of early desaturation following upper airway suctioning was higher in patients with a history of frequent upper respiratory tract infection (P < 0.01). Five patients (5%) had laryngospasm following the LMA removal; breath-holding and coughing were noted in 21 (22%) patients. Circulatory reactions to insertion and removal of the LMA were minimal. The incidence of sore throat on the first postoperative day was only 1%. CONCLUSION: LMA can be regarded as a safe product for airway maintenance during ophthalmic surgery with a stable circulation and few complications.

A multivesicular cardiac hydatid cyst with hepatic involvement.

Cardiac hydatid cyst is an uncommon lesion, mostly caused by Echinococcus granulosus. Occurrence of the disease in man appears to be limited geographically to areas where close and continuous contact exists between domesticated carnivores such as dogs and ungulates such as cattle and sheep. Generally cardiac hydatid cysts are univesicular. Here we report our clinical and surgical experience of treatment in a case of a multivesicular cardiac hydatid cyst with hepatic involvement.

Congenital complete atrioventricular block in an infant with long QT syndrome.

A three months old patient with congenital complete atrioventricular block and prolonged QT interval syndrome is presented. Before admission she had had two syncopal attacks. During hospitalization she had an episode of torsade de pointes which was followed by ventricular fibrillation. After a successful cardiopulmonary resuscitation, a permanent epicardial ventricular pacemaker was implanted and she was discharged on propranolol therapy. She is now free of symptoms and doing well, 16 months after discharge.

Cardiac echinococcsis with multivisceral involvement.

Cardiac hydatid cyst is an uncommon lesion. The infection, often acquired by children during play with infected dogs, is most common in sheep-raising areas of the world. We report our clinical and surgical experience in the treatment of one of the youngest reported cardiac hydatidosis patients with multivisceral involvement.

Comparison of intraarticular bupivacaine with the addition of morphine or fentanyl for analgesia after arthroscopic surgery.

A randomized study on 30 patients undergoing knee arthroscopy was performed. Group I (n = 15) received 50 mg of 0.25% bupivacaine and 1 mg of morphine, and group II (n = 15) received 50 mg of 0.25% bupivacaine and 100 micrograms of fentanyl. The visual analogue scale was recorded at intervals of 1, 2, 3, 4, 6, 12, 24, and 48 hours after the operation. Supplementary analgesia requirements were also recorded. In group I, pain scores were lower than group II (P < .05) during the 1st, 2nd, 3rd, 12th, 24th, and 48th hours. The duration of analgesia on group I was significantly longer than group II. The combination of intraarticular morphine and bupivacaine has a longer analgesic duration and effect than a combination of fentanyl and bupivacaine.

Clinical evaluation of the Omniscience cardiac valve prosthesis. Follow-up of up to 6 years.

From January 1984 to June 1989, 259 Omniscience valve prostheses were implanted in 225 patients. Of the 225 patients; 143 (63.6%) received mitral, 48 (21.3%) aortic, and 34 (15.1%) double valve replacements. The early mortality rate was 8.9%; 97.6% of the patients were included in this study. These patients represent a cumulative follow-up of 407.9 patient-years, with a mean follow-up of 2.03 +/- 0.1 (standard error) years. The late mortality rate was 4.03% overall, which corresponds to 2.0% +/- 0.7%/pt-yr (SE). The annual rate of valve endocarditis was 1.0% +/- 0.5%/pt-yr (SE). The linearized rate of thromboembolism was 1.2% +/- 0.5%/pt-yr (SE). Anticoagulant-related hemorrhage occurred in 15 patients with an annual rate of 3.7% +/- 0.9%/pt-yr (SE). The linearized rate of valve thrombosis was 0.2% +/- 0.2%/pt-yr (SE). By echocardiography the mean mitral valve opening was 75.9 +/- 3.1 degrees (standard deviation) for 27 patients. During follow-up study, 136 (70.8%) patients were in New York Heart Association class I, 44 (22.9%) were in class II, and 12 (6.3%) were in class III; there were 25 (11.1%) patients in class II, 166 (73.8%) in class III, and 34 (15.1%) in class IV preoperatively. Actuarial freedom from thromboembolism was 94.5% +/- 3.6% (SE); freedom from endocarditis, 97.8% +/- 1.0% (SE); freedom from anticoagulant-related hemorrhage, 91.5% +/- 2.0% (SE); freedom from valve thrombosis 99.1% +/- 0.8% (SE); and freedom from hemolysis 98.5% +/- 1.2% (SE). Actuarial survival at 6 years is 94.0% + 2.3% (SE) overall. In conclusion, the overall rate of valve-related complications with this valve is low.

Successful nonsurgical therapy of mural thrombosis of the left atrium after mitral valve replacement.

Mural thrombosis of the left atrium is a complication of mitral valve replacement. In this report we present a case of mural thrombosis of the left atrium after mitral valve replacement treated successfully without surgical intervention.

The triad of persistent left superior vena cava connected to the coronary sinus, right superior vena cava draining into the left atrium, and atrial septal defect: report of a successful operation for a rare anomaly.

The triad of right superior vena cava connecting to the left atrium, persistent left superior vena cava draining into the right atrium (coronary sinus), and atrial septal defect is a rare malformation. Recently, we successfully corrected this anomaly in a 47-year-old man.