Placenta previa percreta involving the left broad ligament and cervix. A case report.

BACKGROUND: Placenta previa percreta with invasion of the broad ligament and uterine cervix is an extremely rare condition and carries high maternal and fetal morbidity and mortality. CASE: A 39-year-old, multiparous woman with two previous cesarean sections presented in active labor at term with placenta previa percreta involving the left broad ligament and cervix. The patient was managed by antepartum diagnosis of placenta previa accreta, supracervical hysterectomy, and blood transfusion. CONCLUSION: This case was managed consistent with the literature, and favorable maternal and fetal outcomes were achieved.

Rabbit esophageal cells show regulatory volume decrease: ionic basis and effect of pH.

BACKGROUND: Regulatory volume decrease (RVD) after osmotic cellular swelling has been shown in several gastrointestinal epithelia but not in esophageal cells. In acid reflux disease, esophageal injury may be related in part to loss of RVD. METHODS: Isolated basal esophageal cells were exposed to an external hyposmolar solution, and changes in relative cell size were assessed using a Coulter counter (Hilaleah, FL) in the presence of K+ and Cl- transport inhibitors and at varying extracellular pH (pHo). RESULTS: At pHo 7.4, a 30% hyposmotic dilution of the external solution caused an initial peak cell swelling (1.15 +/- 0.05-fold) followed by a return to starting cell size by 5 minutes (RVD). RVD was inhibited by Ba2+ (4 mmol/L), quinine (1 mmol/L), or increasing the [K+]o > or = 10 mmol/L. RVD was also inhibited by depleting [Cl-]i or in the presence of 0.5 mmol/L 4,4'-diisothiocyanastostilbene-2,2'-disulfonic acid disodium salt (DIDS) or 50 mumol/L diphenylamine-2-carboxylate, a Cl- conductance inhibitor. To test the effect of pH on RVD, cells in solutions at pHo 7.4, 7.0, or 6.8 were subjected to hyposmotic stress; RVD was significantly inhibited at pHo 6.8. This pH-dependent inhibition of RVD was reversed in the presence of valinomycin, a K+ ionophore. CONCLUSIONS: These studies show that isolated esophageal cells possess RVD mechanisms that are mediated by Cl(-)- and pH-dependent K+ effluxes. RVD appears to be inhibited by a decrease in pHo, suggesting the possibility that acid-induced esophageal injury results from inhibition of normal volume regulatory mechanisms.

Rabbit esophageal cells possess K+ channels: effect of hyposmotic stress on channel activity.

BACKGROUND: In many cell types, basolateral K+ channels are important in maintaining transepithelial Na+ absorption and regulatory volume decrease (RVD) after hyposmolar stress. However, in the esophagus the effect of K+ transport in maintaining baseline short-circuit current (SCC) (Na+ absorption) and RVD is unknown. METHODS: Ussing chambers were used to evaluate changes in SCC of rabbit esophageal mucosa in response to serosal Ba2+ (4 mmol/L), quinine (1 mmol/L), and increasing serosal [K+]. To determine whether K+ channel(s) are activated in RVD, changes in SCC in response to serosal hyposmolarity (156 mOsm) were assessed in the presence or absence of serosal quinine. RESULTS: Serosal Ba2+, quinine, or increased serosal [K+] caused a decline in baseline SCC. Serosal hyposmolarity caused an increase in SCC that was not blocked by mucosal application of amiloride (10(-4) mmol/L). In contrast, serosal quinine completely blocked the hyposmolar-induced increase in SCC. CONCLUSIONS: These studies suggest that rabbit esophageal cells possess Ba(2+)- and quinine-sensitive basolateral K+ channel(s) that are active under baseline conditions. Potassium conductance(s) also appear to be activated by external serosal hyposmolarity and may be involved in the process of RVD.

Autonomic hyperreflexia during cystoscopy in patients with high spinal cord injuries.

Cystoscopic procedures were performed on 102 patients with histories of traumatic spinal cord lesion; 57 patients had sensorimotor levels above T7, and the remaining 45 patients had levels below T7. In 40 of the 57 patients (70 per cent) with levels above T7, signs and symptoms of autonomic hyperreflexia were seen during bladder distension and cystoscopy; the remaining 17 of these patients (30 per cent) did not have this response. No autonomic hyperreflexia was seen during cystoscopy in any of the 45 patients with sensorimotor levels below T7.

Naloxone antagonism after narcotic-supplemented anesthesia.

Narcotic-supplemented balanced anesthesia is increasing in popularity; however, the narcotic must frequently be antagonized postoperatively. Authorities differ in their recommendations as to dose and as to mode and duration of administration of the narcotic antagonist. In the present study of 58 patients undergoing narcotic-supplemented anesthesia, 60 percent of 42 fentanyl patients and 81 percent of 16 morphine patients required postsurgical naloxone for respiratory inadequacy. Naloxone dosage was initially 1.5 mug/kg IV, with repeat IV doses of 1.5 mug/kg, when needed, at 3-minute intervals, until a regular respiratory rate greater than 15 breaths/min was attained. None of the fentanyl patients and only 25 percent (4/16) of the morphine patients required additional naloxone in the recovery room. For the latter, the dose of naloxone previously administered was given IM and proved satisfactory. Additional analgesia was needed by 12 percent (7/58) of the patients during the recovery room stay. Judicious naloxone titration permitted respiratory adequacy to coexist with analgesia after narcotic-supplemented anesthesia.

Endotracheal intubation and Venturi (jet) ventilation for laser microsurgery of the larynx.

Meeting the exacting requirements for microsurgery of the larynx is a challenge for the anesthesiologist. To accomplish, the necessary dissection, the otolaryngologist has several requirements. They are a quiet relaxed field, excellent illumination with magnification, binocular vision for depth perception, and, above all, an unobstructed field. The management of anesthesia for suspension microsurgery on the larynx presents many problems, the most vexing of which is the fact that the otolaryngologist and anesthesiologist are in competition for access to the patient's airway. In sharing this, neither has been able to perform with the degree of control that he would like due to either inadequate operating conditions or insufficient access to ventilatory mechanisms. Several anesthetic techniques have been used for inspection or operative laryngoscopy: topical anesthesia, apneic techniques, translaryngeal topical anesthesia, chest respirator, neuroleptanalgesia, and general endotracheal anesthesia with muscle relaxants. The latter has proven most popular, particularly in children, because ventilation and surgical conditions are considered to be most controllable. However, the presence of the requisite endotracheal tube obscures the full view of the larynx and vocal cords, and the tube may itself become obstructed. Additionally, use of the laser involves the further risk of heat effects on the endotracheal tube if the beam hits the tube. This report presents our experience and development of the combined technique of endotracheal intubation and Venturi (jet) ventilation. We believe it represents the safest available approach while providing near ideal working conditions for the otolaryngologist during laser microsurgery of the larynx.

Corneal injuries during general anesthesia.

A corneal abrasion is the most common eye complication during general anesthesia and recovery. It is painful, may progress to inflammation of the uveal tract, and in the presence of contamination may lead to a serious infection. Both eyes may be involved, as the two reported cases show. Possible causes include mask friction on the open eye or other careless technics. Treatment includes local application of an antibiotic ointment and an eye pressure patch. In addition, a cycloplegic and mydriatic solution is instilled to prevent synechiae (in the presence of a secondary iridocyclitis) and to relieve the pain associated with spasm of the iris and ciliary muscle. Topical application of local anesthetics should be avoided, as they delay regeneration of corneal epithelium and may promote keratitis.