Pericardiectomy: a functional anatomical perspective for the choice of left anterolateral thoracotomy.

Although pericardiectomy remains an established method for pericardial resection, the choice of surgical approach is not definitive. Within South Africa, surgical referral for tuberculosis-induced chronic constrictive pericarditis has not declined. Anecdotal reports have indicated good operative results that appear to show an association with choice of surgical technique used. This study aimed to provide a functional anatomical perspective for performance and recovery of the heart during pericardiectomy based on anatomical dissection and surgical notes. En bloc specimens were harvested from 16 fresh cadavers and pericardial segments were measured in terms of percentage cover over surface area of the myocardium. Retrospective analysis of 116 surgical reports of pericardiectomy performed over a period of 20 years was conducted. Surgical notes were compared for median sternotomy and anterolateral left thoracotomy. Results from anatomical study indicated that although the anterior pericardium between the phrenic nerves constitutes about 58% of total selected pericardial area, total pericardium accessible over left ventricle from that approach was only 26%. When orientated in left anterolateral position, total accessible area of left ventricular pericardium was 37%. Standard deviations were found to be comparable. Means were significantly different, indicating that the left anterolateral approach allows wider access to the left ventricle. This paper provides a functional anatomical perspective for the choice of left anterolateral thoracotomy as a surgical approach for pericardiectomy.

Computerized monitoring of depth of anaesthesia with isoflurane.

Changes in brain activity were studied at different depths of isoflurane anaesthesia. Ten healthy women (ASA group I) were investigated during non-critical surgery. Two channels of the EEG were stored on tape simultaneously with alveolar concentration of carbon dioxide, inspired oxygen concentration, mean arterial pressure, ECG and temperature. Signal processing was made offline. Spectral information from 2-s EEG segments was extracted using autoregressive modelling. Repetitive hierarchical clustering was used to define a common learning set of basic patterns. With this learning set, the EEG was classified, and the results presented in a class probability histogram. The basic patterns were related to the clinical depth of anaesthesia in all patients and assigned specific colours. Using this colour code, the class probability histogram showed a high degree of simplicity. Decreasing or increasing the isoflurane concentration caused the same trend in the class profile in all patients. This indicates that the EEG pattern might be a sensitive tool for decision making during administration of general anaesthetics.

[Effects of induction and supplementary doses of atracurium. Dose-response relationship, spontaneous reversion period, cardiovascular effect and clinical signs of histamine liberation]. / Wirkung der Induktions- und Ergänzungsdosen von Atracurium. Dosis/Response-Verhältnis, spontane Reversionszeit, kardiovaskuläre Effekte und klinische Zeichen einer Histaminfreisetzung.

The effects of an induction dose of atracurium 0.6 mg/kg and supplementary doses of 0.2 mg/kg and 0.1 mg/kg were investigated in 20 patients undergoing non-urgent laparotomy while anesthetized with halothane-N2O-O2. Atracurium was the only muscle relaxant used. Complete neuromuscular block was achieved in all patients, lasting an average of 37 min. Following a supplementary dose of 0.2 mg/kg or 0.1 mg/kg the neuromuscular block was extended on average for a further 25 min (range 13-37 min) or 15 min (range 5-30 min), respectively. The time to spontaneous reversion of complete neuromuscular block at TOF = 0.75 was 39 min (mean). Neither blood pressure nor pulse rate changed significantly following injection of the induction dose. In 3 patients (15%) there was a brief period of erythema with no simultaneous change in pulse rate or blood pressure after administration of the induction dose. The erythema did not recur in the same patients following the supplementary doses. Transitory rises in AST and LDH were noted in 1 patient.

The clinical outcome of patients with severe head injuries, treated with highdose dexamethasone, hyperventilation and barbiturates.

The outcome in 45 consecutive patients following severe head injuries is presented. All patients were evaluated according to the Glasgow Coma Scale and the Glasgow Outcome Scale. All patients received a combined treatment consisting of dexamethasone, barbiturate and hyperventilation. A primary operative intervention was performed in 14 patients with intracranial haematomas. There was a good recovery in 53%, 20% were moderately disabled, 11% were severely disabled. 16% died or remained in a vegetative state. The patients were aged between 5 and 83 years, 49% were under 20 years, and the relationship between age and outcome was demonstrated. 86% of the patients under 20 years and 60% over 20 years made a good recovery. These results indicate that a more favourable prognosis is possible after severe head injury, especially in children and thus the combined treatment described above appears justified.

Cross-infection from contaminated anaesthetic equipment. A real hazard?

A definite relationship between the use of contaminated anaesthetic equipment and subsequent pulmonary infection remains to be established. There is however indirect and circumstantial evidence suggesting that cross-infection may occur, and further an increased susceptibility of surgical patients to pulmonary infections has been demonstrated. Decontamination should be recommended before the equipment is re-used. Pasteurisation may prove sufficient and this can be obtained employing a specially designed dish-washing machine.

The ejector flowmeter as air/oxygen mixing device. An apparatus providing gas mixtures with adjustable oxygen content for high-flow humidification systems.

The ejector flowmeter is constructed for continuous removal of excess gas from anaesthetic circuits. This instrument can be used as an air/oxygen mixing device for high-flow humidification systems in wards where compressed air is not available. Pure oxygen is used as driving gas through the ejector. A nomogram has been constructed to show the relationship between oxygen driving pressure, inlet of air to the flowmeter, FIO2 and total outflow.

Blood pressure response to administration of local anaesthetics with noradrenaline in craniotomies.

Infiltration with local anaesthetics with addition of adrenaline or noradrenaline has been used since 1910 prior to skin incision for craniotomy. In a controlled series of patients scheduled for intracranial operations, systemic blood pressure was measured intra-arterially after infiltration with 15-20 ml 0.5% lignocaine with nonradrenaline 1 mu gr/ml. A marked increase in systemic blood pressure was seen (125% of values prior to infiltration). In a control series, where saline was injected, a slight fall in blood pressure was registered (p smaller than 0.01). As hypertensive episodes increase intracranial pressure in patients with impaired cerebral autoregulation, or promote the risk of haemorrhage in aneurysm surgery, this technique is considered a hazard to patients undergoing intracranial operations.

Cameco anaesthetic ventilator with a modified Mapleson D circuit.

A modified Mapleson D circuit has been used in connection with a Cameco anaesthetic ventilator during neuroradiological procedures in general anaesthesia. In order to increase mobility of the patient, two or three lengths of corrugated rubber tubing were used to connect the patient to the ventilator. Blood gas analysis was carried out in 20 patients after ventilation to steady state with both circuits. The respiratory minute volume and fresh gas flow were preset in Bain's (Bain & Spoerel 1975) predictions. No significant difference could be detected in respect to Paco2 or Po2, whether 2 or 3 lengths of tubing were used. Mean values of Paco2 were higher compared with the results of Bain (0.37 kPa s.d. 0.50). It is concluded that this system gives maximum mobility of the patient during the radiological procedure and offers reliable adjustment of Paco2, even in patients with apparent increase of intracranial pressure.