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1.
Anaesth Crit Care Pain Med ; 42(1): 101178, 2023 02.
Artigo em Inglês | MEDLINE | ID: mdl-36442803

RESUMO

BACKGROUND: During liver transplantation, graft reperfusion triggers cerebral hyperemia, increases intracranial pressure, and disrupts the blood-brain barrier, thereby increasing the risk for immunosuppression neurotoxicity. Therefore, we tested the intraoperative optic nerve sheath diameter (ONSD) for predicting tacrolimus neurotoxicity after liver transplantation. BASIC PROCEDURES: We prospectively included 100 adult patients who underwent living donor liver transplantation. The ultrasonographic ONSD 5 min after reperfusion was used as the index test, whereas the occurrence of early tacrolimus neurotoxicity was used as the reference. The area under the receiver operating characteristic curve (AUROC) was used to estimate the ONSD prediction accuracy. We reported the specificity and sensitivity of ONSD 5 and 30 min after reperfusion. Cutoffs were derived from the ROC curves. In addition, we used regression to control for confounders while testing the association between the ONSD and tacrolimus neurotoxicity. MAIN FINDINGS: The AUROC at T3 was 0.74 (95% confidence interval (CI), 0.63-0.85, P < 0.001). An ONSD of ≥6.4 mm at T3 had an 86% sensitivity (95% CI, 68%-96%) and 53% specificity (95% CI, 41%-65%). An ONSD of ≥6.4 mm at T3 had an adjusted odds ratio for tacrolimus neurotoxicity of 6.3 (95% CI, 1.9-21, P = 0.003). CONCLUSIONS: This data indicates that intraoperative ultrasonic ONSD after reperfusion can predict tacrolimus neurotoxicity after liver transplantation. TRIAL REGISTRATION: NCT03799770; registered on January 1st, 2019.


Assuntos
Transplante de Fígado , Adulto , Humanos , Transplante de Fígado/efeitos adversos , Doadores Vivos , Nervo Óptico/diagnóstico por imagem , Curva ROC , Tacrolimo/efeitos adversos , Ultrassonografia
2.
Indian J Anaesth ; 67(11): 991-998, 2023 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-38213689

RESUMO

Background and Aims: Post-reperfusion syndrome (PRS) is a serious haemodynamic event during liver transplantation (LT), which increases early graft dysfunction and mortality. This study aimed to test the efficacy and safety of norepinephrine (NE) boluses to prevent PRS during orthotopic LT. Methods: This feasibility phase II trial prospectively recruited a single arm of 40 patients undergoing living donor LT. The intervention was an escalated protocol of NE boluses starting at 20 µg. The primary outcome was the incidence of PRS. The secondary outcomes were arrhythmia, electrocardiographic (EKG) ischaemic changes, mean pulmonary pressure after reperfusion, 3-month survival and 1-year survival. Results: PRS occurred in 28 (70%) cases [95% confidence interval (CI) 54% to 83%, P < 0.001], with a relative risk reduction of 0.22 when compared to our previous results (90%). Twelve cases developed transient EKG ischaemic changes. All EKG ischaemic changes returned to baseline after correction of hypotension. There was no significant arrhythmia or bradycardia (95% CI 0 to 0.9). After reperfusion, the mean pulmonary artery pressure was not significantly higher than the normal limit (20 mmHg) (P = 0.88). The 3-month survival was 0.95 (95% CI 0.83 to 0.99), and the 1-year survival was 0.93 (95% CI 0.8 to 0.98). Conclusion: Our findings suggest that NE boluses starting with 20 µg is feasible and effective in lowering the risk of PRS during living donor LT. Additionally, NE boluses were not associated with significant myocardial ischaemic events, arrhythmia or a rise in pulmonary pressure.

3.
Int Orthop ; 45(10): 2491-2498, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-34232361

RESUMO

INTRODUCTION: Segmental skeletal defects are very difficult to treat. The current options are lengthy procedures, require more than one surgery and plagued with many complications. The aim of this study is to assess the results of bone graft in surgicel as a synthetic membrane for reconstruction of segmental skeletal defects in one stage surgery. METHODS: Fourteen patients with segmental skeletal defects were included in the study. The ages ranged from 20 to 54 years with an average of 32 years. The defects were due to high energy trauma in all cases. The size of the defects ranged from 5 to 12 cm with an average of 7 cm. They were located in the distal femur in 11 cases and middle third of the femur in three cases. All cases were treated by the synthetic membrane technique in one stage surgery. Surgicel was used as a synthetic membrane and both the fibular strut autograft and morselized allograft were used to fill the defects in all patients. RESULTS: All cases healed without additional procedures after the index surgery except in three cases. The time-to-bone union ranged from six to 13 months with an average of eight months. After physiotherapy all patients regained good range of knee movements except two cases. The complications included deep wound infection in two cases, nonunion of the graft in one case and joint stiffness in two cases. CONCLUSION: Primary bone graft in surgicel as a synthetic membrane is a good technique for management of post-traumatic bone defects. It reduces the time and number of surgeries required for reconstruction of this difficult problem.


Assuntos
Transplante Ósseo , Fíbula , Adulto , Fêmur , Humanos , Articulação do Joelho , Pessoa de Meia-Idade , Estudos Retrospectivos , Transplante Autólogo , Resultado do Tratamento , Adulto Jovem
4.
Int J Surg Case Rep ; 49: 158-162, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30007264

RESUMO

INTRODUCTION: Biliary reconstruction is a cornerstone of living-donor liver transplantation (LDLT). The routine uses of trans-anastomotic biliary catheters in biliary reconstruction had been a controversial issue. We describe a rare complication related to the use of trans-anastomotic biliary catheter after LDLT. In this case, intestinal obstruction occurred early after LDLT due to internal herniation of the small bowel around trans-anastomotic biliary catheter. PRESENTATION: A 42 years male patient with end stage liver disease underwent LDLT utilizing a right hemi-liver graft. Biliary reconstruction was done by single duct-to-duct anastomosis over trans-anastomotic biliary catheter. The patient was doing well apart from early postoperative ascites that was managed medically. Three weeks after surgery, the patient developed severe agonizing central abdominal pain not responding to anti-spasmodics and analgesics. The decision was to proceed for surgical exploration. Exploration revealed internal herniation of the small bowel loops around the trans-anastomotic biliary catheter without strangulation. Reduction of the internal hernia was done by releasing the fixation of the biliary catheter from the anterior abdominal wall. Small bowel resection was not required. The patient had smooth postoperative course and was discharged 10 days after surgery. DISCUSSION: Awareness regarding this rare complication plus early surgical intervention can prevent the development of postoperative morbidity and mortality. To the best of our knowledge this is the first report to describe such are complication after LDLT. CONCLUSION: We report the first case of internal herniation of small bowel around biliary catheter early after LDLT.

6.
Anesth Analg ; 124(4): 1291-1297, 2017 04.
Artigo em Inglês | MEDLINE | ID: mdl-27984230

RESUMO

BACKGROUND: Transversus abdominis plane (TAP) block and local anesthetic wound infiltration provide analgesia after cesarean delivery. Studies comparing the 2 techniques are scarce, with conflicting results. This double-blind, randomized controlled trial aimed to compare bilateral ultrasound-guided TAP block with single-shot local anesthetic wound infiltration for analgesia after cesarean delivery performed under spinal anesthesia. We hypothesized that the TAP block would decrease postoperative cumulative fentanyl consumption at 24 hours. METHODS: Eligible subjects were American Society of Anesthesiologists physical status II parturients with full-term singleton pregnancies undergoing elective cesarean delivery under spinal anesthesia. Exclusion criteria were: <19 years of age or >40 years of age; height <150 cm, weight <60 kg, body mass index ≥40 kg/m; contraindications to spinal anesthesia; history of recent opioid exposure; hypersensitivity to any of the drugs used in the study; significant cardiovascular, renal, or hepatic disease; and known fetal abnormalities. Eighty subjects were randomly allocated to 2 equal groups. In the infiltration group, participants received 15 mL of bupivacaine 0.25% in each side of the surgical wound (total 30 mL); and in the TAP group, participants received 20 mL of bupivacaine 0.25% bilaterally in the TAP block (total 40 mL). The TAP block and wound infiltration were performed by the primary investigator and the operating obstetrician, respectively. All participants received postoperative standard analgesia (ketorolac and paracetamol) and intravenous fentanyl via patient-controlled analgesia. Patients and outcome assessors were blinded to the study group. The primary outcome was the cumulative fentanyl consumption at 24 hours. Secondary outcomes were the time to the first postoperative fentanyl dose, cumulative fentanyl consumption at 2, 4, 6, and 12 hours, pain scores at rest and on movement at 2, 4, 6, 12, and 24 hours, the deepest level of sedation, the incidence of side effects (nausea and vomiting and pruritis), and patient satisfaction. RESULTS: Data from 78 patients (39 patients in each group) were analyzed. The mean ± SD of cumulative fentanyl consumption at 24 hours was 157.4 ± 63.4 µg in the infiltration group and 153.3 ± 68.3 µg in the TAP group (difference in means [95% confidence interval] is 4.1 [-25.6 to 33.8] µg; P = .8). There were no significant differences between the 2 groups in the time to the first postoperative fentanyl dose, cumulative fentanyl consumption at 2, 4, 6, and 12 hours, pain scores at rest and on movement at 2, 4, 6, 12, and 24 hours, the deepest level of sedation, and patient satisfaction. The incidence of side effects (nausea and vomiting and pruritis) was low in the 2 groups. CONCLUSIONS: TAP block and wound infiltration did not significantly differ regarding postoperative fentanyl consumption, pain scores, and patient satisfaction in parturients undergoing cesarean delivery under spinal anesthesia.


Assuntos
Músculos Abdominais , Analgesia Obstétrica/métodos , Cesárea/efeitos adversos , Bloqueio Nervoso/métodos , Dor Pós-Operatória/prevenção & controle , Ferida Cirúrgica/tratamento farmacológico , Músculos Abdominais/efeitos dos fármacos , Adulto , Cesárea/métodos , Método Duplo-Cego , Feminino , Humanos , Manejo da Dor/métodos , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/etiologia , Projetos Piloto , Gravidez , Ferida Cirúrgica/diagnóstico , Ferida Cirúrgica/etiologia , Adulto Jovem
7.
Anesth Analg ; 124(3): 851-856, 2017 03.
Artigo em Inglês | MEDLINE | ID: mdl-27183373

RESUMO

BACKGROUND: Preprocedural ultrasound may improve the efficacy and safety of epidural catheterization, especially in difficult cases. Most studies of ultrasound-assisted epidural catheterization in the obstetric population are dated and nonblinded with inconsistent designs. This double-blind, randomized controlled study aimed to compare the ultrasound-assisted with the conventional palpation techniques for epidural catheterization in parturients undergoing cesarean delivery. We hypothesized that the use of preprocedural ultrasound would increase the success rate of epidural catheterization at the first needle pass. METHODS: Eligible subjects were American Society of Anesthesiologists physical status II parturients with full-term singleton pregnancy undergoing elective cesarean delivery using double-interspace combined spinal-epidural anesthesia. Exclusion criteria were age <19 or >40 years, body mass index ≥35 kg/m, women presenting in labor or having any contraindication to neuraxial anesthesia, marked spinal deformity, previous spinal surgery, or impalpable anatomical landmarks. One hundred ten patients were randomly allocated into 2 equal groups (palpation and ultrasound groups). All procedures were performed by a single experienced anesthesiologist. Patients and investigators assessing the outcome data were blinded to group allocation. A systematic spinal ultrasound assessment and a sham procedure were performed in the ultrasound and palpation groups, respectively, before attempting epidural catheterization. The primary outcome was the rate of successful epidural catheterization at the first needle pass. Secondary outcomes were the rate of successful epidural catheterization at the first skin puncture, number of performed needle passes and skin punctures, duration of the epidural procedure, patient satisfaction from the procedure, and complications of the procedure (incidence of unintentional dural and vascular punctures, failed block, unilateral or patchy block, and backache). RESULTS: Data from 108 patients (55 patients in the palpation group and 53 patients in the ultrasound group) were analyzed. The rate of successful epidural catheterization at the first needle pass was 60% in the palpation group and 58.5% in the ultrasound group (95% confidence interval of the difference in proportions between groups is -18.5% to 21.6%; P > 0.99). There were no significant differences between the 2 groups in the success rate at the first skin puncture, the number of needle passes and skin punctures, or patient satisfaction. The median (range) duration of the epidural procedure was 185 (57-680) seconds in the ultrasound group and 215 (114-720) seconds in the palpation group (P = 0.036 with the Mann-Whitney U test and P = 0.083 with the Student t test with unequal variances). The overall rate of complications of the procedure was low in both groups. CONCLUSIONS: For experienced anesthesiologists, it remains unclear whether preprocedural ultrasound improves the epidural catheterization technique in parturients with palpable anatomical landmarks undergoing cesarean delivery.


Assuntos
Analgesia Epidural/métodos , Analgesia Obstétrica/métodos , Cesárea/métodos , Espaço Epidural/diagnóstico por imagem , Cuidados Pré-Operatórios/métodos , Ultrassonografia de Intervenção/métodos , Adulto , Analgesia Epidural/instrumentação , Analgesia Obstétrica/instrumentação , Cateterismo/instrumentação , Cateterismo/métodos , Cesárea/instrumentação , Método Duplo-Cego , Feminino , Humanos , Trabalho de Parto/efeitos dos fármacos , Trabalho de Parto/fisiologia , Gravidez , Cuidados Pré-Operatórios/instrumentação , Ultrassonografia de Intervenção/instrumentação
8.
J Pediatr Orthop B ; 25(6): 556-60, 2016 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-27243804

RESUMO

The aim of this study was to compare the results of treatment of segmental tibial defects in the pediatric age group using an Ilizarov external fixator versus a nonvascularized fibular bone graft. This study included 24 patients (age range from 5.5 to 15 years) with tibial bone defects: 13 patients were treated with bone transport (BT) and 11 patients were treated with a nonvascularized fibular graft (FG). The outcome parameters were bone results (union, deformity, infection, leg-length discrepancy) and functional results: external fixation index and external fixation time. In group A (BT), one patient developed refracture at the regenerate site, whereas, in group B (FG), after removal of the external fixator, one of the FGs developed a stress fracture. The external fixator time in group A was 10.7 months (range 8-14.5) versus 7.8 months (range 4-11.5 months) in group B (FG). In group A (BT), one patient had a limb-length discrepancy (LLD), whereas, in group B (FG), three patients had LLD. The functional and bone results of the Ilizarov BT technique were excellent in 23.1 and 30.8%, good in 38.5 and 46.2, fair in 30.8 and 15.4, and poor in 7.6 and 7.6%, respectively. The poor functional result was related to the poor bone result because of prolonged external fixator time resulting in significant pain, limited ankle motion, whereas the functional and bone results of fibular grafting were excellent in 9.1 and 18.2%, good in 63.6 and 45.5%, fair in 18.2 and 27.2%, and poor in 9.1 and 9.1%, respectively. Segmental tibial defects can be effectively treated with both methods. The FG method provides satisfactory results, with early removal of the external fixator. However, it had a limitation in patients with severe infection and those with LLD. Also, it requires a long duration of limb bracing until adequate hypertrophy of the graft. The Ilizarov method has the advantages of early weight bearing, treatment of postinfection bone defect in a one-stage surgery, and the possibility to treat the associated LLD. However, it has a long external fixation time.


Assuntos
Fíbula/cirurgia , Técnica de Ilizarov , Desigualdade de Membros Inferiores/cirurgia , Tíbia/cirurgia , Fraturas da Tíbia/cirurgia , Adolescente , Transplante Ósseo , Criança , Pré-Escolar , Desbridamento , Fixadores Externos , Feminino , Consolidação da Fratura , Humanos , Masculino
9.
J Clin Monit Comput ; 30(6): 857-858, 2016 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-26410409

RESUMO

Preprocedural spinal ultrasound appears to decrease the failure rate and complications of neuraxial anesthesia compared to the conventional landmark technique. It is especially beneficial in difficult cases where conventional palpation technique may fail. We recently encountered a parturient with multiple lumbar and cervical spinal metastatic lesions presenting for cesarean section in the third trimester. We used spinal ultrasound to define the appropriate intervertebral space and measure the distance to the ligamentum flavum-dura mater complex. This greatly helped in administering a safe spinal anesthetic and avoiding general anesthesia which might have been hazardous in this patient.


Assuntos
Anestesia Obstétrica/métodos , Raquianestesia/métodos , Neoplasias Ósseas/patologia , Cesárea , Neoplasias da Coluna Vertebral/patologia , Ultrassonografia de Intervenção , Adulto , Feminino , Humanos , Vértebras Lombares/patologia , Metástase Neoplásica , Coluna Vertebral/fisiopatologia
10.
Eur J Orthop Surg Traumatol ; 23(4): 443-8, 2013 May.
Artigo em Inglês | MEDLINE | ID: mdl-23412149

RESUMO

AIM: The purpose of this study is to evaluate the clinical and radiological outcomes of cemented bipolar arthroplasty as a primary treatment for unstable intertrochanteric fracture in the elderly patients. METHODS: Twenty hips with unstable intertrochanteric fractures were followed for more than 2 years after cemented bipolar hemiarthroplasty. The mean age was 69 years, and the mean follow-up period was 30.5 months. We evaluated the results by Harris hip score, complications, and radiologic findings. RESULTS: At the last follow-up, the mean Harris hip score was 83.3 points. Radiologically, there was no case of osteolysis. All stems were stable without significant changes in alignment or progressive subsidence. CONCLUSIONS: Bipolar hemiarthroplasty with calcar reconstruction is a good option for unstable intertrochanteric fractures in elderly patients with severe osteoporosis with strict indication selection. Longer-term studies with larger numbers of patients are required to address the issues of late complications.


Assuntos
Artroplastia de Quadril , Cimentação , Hemiartroplastia , Fraturas do Quadril , Fraturas por Osteoporose , Complicações Pós-Operatórias/prevenção & controle , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Artroplastia de Quadril/efeitos adversos , Artroplastia de Quadril/instrumentação , Artroplastia de Quadril/métodos , Cimentação/efeitos adversos , Cimentação/métodos , Egito , Feminino , Fêmur/diagnóstico por imagem , Fêmur/cirurgia , Fraturas Cominutivas/diagnóstico por imagem , Fraturas Cominutivas/cirurgia , Hemiartroplastia/efeitos adversos , Hemiartroplastia/instrumentação , Hemiartroplastia/métodos , Fraturas do Quadril/diagnóstico por imagem , Fraturas do Quadril/etiologia , Fraturas do Quadril/cirurgia , Humanos , Tempo de Internação , Masculino , Fraturas por Osteoporose/diagnóstico por imagem , Fraturas por Osteoporose/cirurgia , Avaliação de Resultados em Cuidados de Saúde , Estudos Prospectivos , Radiografia
11.
Strategies Trauma Limb Reconstr ; 6(1): 1-6, 2011 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-21589675

RESUMO

Between 2002 and 2007, fifty elderly patients with displaced femoral neck fractures were treated with hip replacement at Emergency Hospital, Mansoura University. Patients were randomly selected, 25 patients had either cemented or cementless bipolar prosthesis, and another 25 patients had either cemented or cementless fixed-head prosthesis. There were 34 women and 16 men with an average age of 63.5 years (range between 55 and 72 years). All patients were followed up both clinically and radiologically for an average 4.4 years (range between 2 and 6 years). At the final follow-up, the average Harris hip score among the bipolar group was 92 points (range between 72 and 97 points), while the fixed-head group was 84 points (range between 65 and 95 points). Radiologically, joint space narrowing more than 2 mm was found in only 8% (2 patients) among the bipolar group, and in 28% (7 patients) of the fixed-head group. Through the follow-up period, total hip replacement was needed in two cases of the bipolar group and seven cases of the fixed-head group. Bipolar hemiarthroplasty offered a better range of movement with less pain and more stability than the fixed-head hemiarthroplasty in elderly patients with displaced femoral neck fractures.

12.
Acta Orthop Belg ; 75(6): 748-53, 2009 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-20166356

RESUMO

Intertrochanteric fractures of the femur were treated with an external fixator in 38 elderly high-risk patients between November 2005 and February 2007. The mean operation time was 25 min (range: 20 to 32 min), the mean fluoroscopy time was 15 sec (range: 10 to 18 sec), and the mean hospital stay was four days (range: 3 to 7 days). The average time to union was 9.5 weeks. No deep pin track infections occurred; superficial skin inflammation was seen in 30%. Implant failure or knee stiffness were noted in no instance. At the latest follow-up, the mean femoral shaft-neck angle was 130 degrees (range: 116 degrees to 138 degrees), the average Harris hip score was 64 (range: 50-80). Mortality rate was 8% at 6 months from causes unrelated to the operation. The use of a multiplanar external fixator in these patients provided a satisfactory stability, reduced their time in hospital and facilitated their postoperative rehabilitation.


Assuntos
Fixadores Externos , Fraturas do Quadril/cirurgia , Idoso , Idoso de 80 Anos ou mais , Parafusos Ósseos , Feminino , Fraturas do Quadril/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Radiografia
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