Hemodynamic stability ensured by a low dose, low volume, unilateral hypobaric spinal block: modification of a technique.

We report the case of an 89-year-old female with a history of arterial hypertension, intermittent rapid atrial fibrillation and severe aortic valve stenosis, suffering from femoral neck fracture. Hyperbaric unilateral spinal anesthesia is a known technique to obtain stable hemodynamics combined with the possibility of continuous neurologic evaluation and preservation of cognitive functions. Because a hyperbaric unilateral technique can be very painful in case of traumatic hip fracture, a low dose, low volume, unilateral hypobaric spinal block may be an adequate alternative. In the present case report, a unilateral hypobaric spinal anesthesia was performed using 5 mg of bupivacaine in a 1.5 mL volume and a slow and steady, "air-buffered", directed injection technique, to allow an urgent hip arthroplasty. During surgery the patient was kept in the lateral recumbent position. Hemodynamics remained stable throughout the entire procedure without any need for vasoconstrictors. The impact of aortic valve stenosis combined with atrial fibrillation on anesthetic management and our considerations to opt for a unilateral hypobaric spinal anesthesia are discussed.

A patient with haloperidol induced laryngeal dystonia.

We discus the case of a forty-nine year old patient with haloperidol induced laryngeal dystonia (LD). Laryngeal dystonia is a life threatening, very rare medical condition which is difficult to diagnose. It can occur after a short treatment of a patient with atypical antipschycotics. LD can induce severe respiratory insufficiency leading to hypoxemia and death. Due to the lack of diagnosis, we performed an emergency tracheotomy because of severe respiratory distress syndrome. An emergency tracheotomy can be a life-saving procedure in patients with LD.

The anatomy of the thoracic spinal canal investigated with magnetic resonance imaging (MRI).

BACKGROUND AND OBJECTIVES: Anesthesiologists are reluctant to consider higher levels for spinal anesthesia, largely due to direct threats to the spinal cord. The goal of this study is to investigate, with magnetic resonance imaging (MRI), the distances between the relevant structures of the spinal canal (spinal cord, thecal tissue, etc.) to determine modal anatomical positions for neuraxial anesthesia. METHOD: A group of 19 patients were imaged with an MRI scanner in supine position. Medial sagittal slices of the thoracic and lumbar spine were measured for the relative distances between anatomical structures, including epidural space, dura, and spinal cord. RESULTS: The posterior dura - spinal cord distance is significantly greater in the middle thoracic region than at upper and lower thoracic levels (e.g. T6 9.5 +/- 1.8 mm, T12 3.7 +/- 1.2 mm, p < 0.001, T1 4.7 +/- 1.7 mm, p < 0.001). There is variation in modal distances between the structures important for neuraxial anesthesia, at different levels of the spinal canal. CONCLUSIONS: The spinal cord tends to follow the straightest line through the imposed geometry of the spine. Considering the necessary angle of entry of the needle at mid-thoracic levels, there is relatively (more than at upper thoracic and lumbar levels) substantial separation of cord and surrounding thecal tissue. Anesthesiologists perform spinal blockades up to the L2-L3 interspace, but avoid higher levels for fear of neurological damage. The information that there is substantially more space in the dorsal subarachnoid space at thoracic level, might lead to potential applications in regional anesthesia. In contrast, the cauda equina sits more dorsally in the lumbar region.

Laparoscopic cholecystectomy under segmental thoracic spinal anaesthesia: a feasibility study.

BACKGROUND: Laparoscopic surgery is normally performed under general anaesthesia, but regional techniques have been found beneficial, usually in the management of patients with major medical problems. Encouraged by such experience, we performed a feasibility study of segmental spinal anaesthesia in healthy patients. METHODS: Twenty ASA I or II patients undergoing elective laparoscopic cholecystectomy received a segmental (T10 injection) spinal anaesthetic using 1 ml of bupivacaine 5 mg ml-1 mixed with 0.5 ml of sufentanil 5 microg ml-1. Other drugs were only given (systemically) to manage patient anxiety, pain, nausea, hypotension, or pruritus during or after surgery. The patients were reviewed 3 days postoperatively by telephone. RESULTS: The spinal anaesthetic was performed easily in all patients, although one complained of paraesthesiae which responded to slight needle withdrawal. The block was effective for surgery in all 20 patients, six experiencing some discomfort which was readily treated with small doses of fentanyl, but none requiring conversion to general anaesthesia. Two patients required midazolam for anxiety and two ephedrine for hypotension. Recovery was uneventful and without sequelae, only three patients (all for surgical reasons) not being discharged home on the day of operation. CONCLUSIONS: This preliminary study has shown that segmental spinal anaesthesia can be used successfully and effectively for laparoscopic surgery in healthy patients. However, the use of an anaesthetic technique involving needle insertion into the vertebral canal above the level of termination of the spinal cord requires great caution and should be restricted in application until much larger numbers of patients have been studied.

Pseudomyxoma peritonei in the pleural cavity: report of a case.

PURPOSE: Pseudomyxoma peritonei is a rare disease characterized by mucinous ascites and associated with ruptured mucocele, cystadenoma, and low-grade carcinoma arising from the appendix, ovaries, or colon. Metastases and extraperitoneal involvement are extremely rare events. METHOD: This is a case report of a patient with pseudomyxoma peritonei with pleural involvement. RESULTS: A 38-year-old male patient with a pseudomyxoma peritonei from appendiceal origin underwent an extensive cytoreduction procedure. During the operation pleural involvement was noted. This was later confirmed by thoracoscopy. An expectant policy was followed until the patient became symptomatic with progressive disease in the abdomen and both pleural cavities. With systemic chemotherapy (5-fluorouracil and leucovorin), a good clinical response was obtained, and the patient was alive with stable disease 2.5 years after the first diagnosis. CONCLUSIONS: Involvement of the pleural cavity by pseudomyxoma peritonei is rare and carries an unfavorable prognosis. Whenever possible, the same guidelines as for intra-abdominal disease should be followed: extensive cytoreductive procedures with local and/or systemic chemotherapy. In our patient we hope to achieve a prolonged palliation with systemic chemotherapy.

Effect of the hemoglobin-based oxygen carrier HBOC-201 on laboratory instrumentation: cobas integra, chiron blood gas analyzer 840, Sysmex SE-9000 and BCT.

As part of a clinical trial, we evaluated the effects of the hemoglobin-based oxygen-carrier (HBOC) HBOC-201 (an ultrapurified, stroma-free bovine hemoglobin product, Biopure, Cambridge, MA, USA) on our routine clinical chemistry analyzer (Cobas Integra, F. Hoffmann-La Roche Ltd, Basel, Switzerland ), blood gas analyzer (Chiron 840, Chiron Diagnostics Corporation, East Walpole, MA, USA), routine hemocytometry analyzer (Sysmex SE-9000, TOA Medical Electronics Co Ltd., Kobe, Japan), hemostasis analyzer (BCT, Dade-Behring, Marburg, Germany) and bloodbanking system (Dia-Med-ID Micro Typing System, DiaMed AG, Cressier, Switzerland). The maximum tested concentration of HBOC-201 was 65 g/l. Of the 27 routine clinical chemistry tests challenged with HBOC-201, bilirubin-direct, creatine kinase MB-fraction (CK-MB), creatine kinase (CK), gamma-glutamyltransferase (GGT), magnesium and uric acid were influenced by even low concentrations of HBOC-201. These tests were excluded from use on the plasma of patients treated with HBOC-201. Since the non-availability of the cardiac marker CK-MB may lead to problems in acute situations, we introduced the qualitative Trop T-test (Boehringer Mannheim), which was not influenced. The applicability of another nine tests was limited by the concentration of the HBOC-201 in the patients' plasma. No interference of HBOC-201 in routine hemocytometry, hemostasis-analysis and red-blood cell agglutination detection (blood-bank tests) was observed. Although immediate patient-care was not compromised, routine use of hemoglobin-based oxygen carriers will have a strong impact on logistical management. The development of robust laboratory tests free from the interference of the pigmented oxygen carriers should therefore precede its introduction into routine transfusion medicine.

Cold storage of the heart with University of Wisconsin solution and 2,3-butanedione monoxime: Langendorff vs isolated working rabbit heart model.

Currently, for clinical heart preservation with University of Wisconsin (UW) solution the ischemic time is limited to 8 h. The reliable preservation of the heart for 24 h or more would have a dramatic impact on the existing practice of cardiac transplantation. We showed previously [J. Thorac. Cardiovasc. Surg. 107; 764-775 (1994)] that experimentally preservation could be extended to 24-30 h by preventing ischemic contracture of the heart with 2, 3-butanedione monoxime (BDM) in the UW solution (UWBDM). This resulted in nearly 100% return of function as tested in the isolated crystalloid-reperfused rabbit heart in the nonworking Langendorff preparation. We have confirmed these results and now have measured the function of hearts stored in UWBDM for 2, 4, 12, and 24 h using the isolated working rabbit heart model. Preservation in UWBDM solution resulted in a biphasic decrease of cardiac output. In the hearts preserved for 2-12 h the decrease of function averaged 20-35% upon reperfusion, and the differences at 2, 4, or 12 h were not significant (analysis of variance p > 0.05). A more pronounced decrease of 64% was obtained after 24 h of cold storage. Hearts preserved for 24 h without BDM were practically nonfunctional. The release of enzymes (creatine kinase and lactate dehydrogenase) followed biphasic pattern similar to that of cardiac output: a small release between 2 and 12 h and larger, significant losses at 24 h. Although we originally proposed that hearts preserved with UWBDM for 24 h were well preserved (Langendorff model), we now show that poor function was obtained at 24 h. The difference was that in this study we used a more rigorous, isolated working rabbit heart model to test the function of the preserved heart, and this may be a better test of preservation quality.

Reductive dechlorination of chlorophenols by a pentachlorophenol- acclimated methanogenic consortium.

Anaerobic digester sludge fed 5,300 mg of acetate per liter, 3.4 microM pentachlorophenol, and nutrients for 10 days biotransformed pentachlorophenol by sequential ortho dechlorinations to produce 2,3,4,5-tetrachlorophenol and 3,4,5-trichlorophenol. Upon acclimation to 3.4 microM pentachlorophenol for 6 months, the methanogenic consortium removed chlorines from the ortho, meta, and para positions of pentachlorophenol and its reductive dechlorination products. Pentachlorophenol was degraded to produce 2,3,4,5-tetrachlorophenol, 2,3,4,6-tetrachlorophenol, and 2,3,5,6-tetrachlorophenol. Dechlorination of 2,3,4,5-tetrachlorophenol produced 3,4,5-trichlorophenol, which was subsequently degraded to produce 3,4-dichlorophenol and 3,5-dichlorophenol. 2,3,4,6-Tetrachlorophenol was dechlorinated at the ortho and meta positions to produce 2,4,6-trichlorophenol and 2,4,5-trichlorophenol. 2,3,5,6-Tetrachlorophenol yielded 2,3,5-trichlorophenol, followed by production of 3,5-dichlorophenol. 2,4,6-Trichlorophenol was degraded to form 2,4-dichlorophenol, and 2,4,5-trichlorophenol was dechlorinated at two positions to form 2,4-dichlorophenol and 3,4-dichlorophenol. Of the three dichlorophenols produced (2,4-dichlorophenol, 3,4-dichlorophenol, and 3,5-dichlorophenol), only 2,4-dichlorophenol was degraded significantly within 3 weeks, to produce 4-chlorophenol.