Novel resuscitation devices facilitate complete neurologic recovery after prolonged cardiac arrest in postanesthesia care unit.

Cardiac arrest in the perioperative period is associated with significant morbidity and mortality. Novel resuscitation devices may afford patients improved survival and limit neurologic injury. We report a case of cardiac arrest in the postanesthesia care unit that required an extensive period of cardiopulmonary resuscitation assisted by the ResQPOD impedance threshold device to optimize coronary perfusion and a LUCAS chest compression system to maintain optimal cardiopulmonary resuscitation while transporting the patient to the cardiac catheterization laboratory. Furthermore, after stabilization for an occluded left anterior descending artery with stent placement, an institutional hypothermia protocol was initiated using Thermogard XP Temperature Management system for 24 hours.

Anesthetic care and perioperative complications in children with Sanfilipo Syndrome Type A.

BACKGROUND: Patients with mucopolysaccharidoses (MPS) are generally considered high risk for anesthesia care, owing to disease-related factors. Sanfilippo syndrome type A (MPS IIIA) is the most frequently occurring MPS. Anesthesia-specific information for MPS IIIA is not readily available in the literature. OBJECTIVES: To report post hoc analyses on anesthesia care and outcomes from a 2-year study of the natural history of patients with untreated MPS IIIA (NCT01047306). METHODS: Subjects were ≥1 year of age, developmental age ≥1 year, and without significant central nervous system impairment (other than that due to MPS IIIA) or issues that would preclude study procedures. Procedures requiring general anesthesia included brain/abdominal magnetic resonance imaging, lumbar puncture, and echocardiography. Sedation, intubation, and extubation procedures as well as postoperative airway problems were recorded at baseline and 6, 12, and 24 months of age. RESULTS: Twenty-five patients (baseline age, 13-220 months) received a total of 94 general anesthetics. Patients successfully received oral sedation prior to 76 of 94 anesthetics. No patients required airway intervention or oxygen supplementation during sedation. All anesthesia providers described facemask ventilation and endotracheal intubations as 'easy'. All subjects were successfully extubated after completion of the procedures. No patients required reintubation. Six (24%) patients had episodes of postoperative airway problems: wheezing (7/94, 7.4%), croup (6/94, 6.4%), and laryngospasm (2/94, 2.1%). CONCLUSION: We found no change in the modified Cormack-Lehane intubation grades in 25 Sanfilippo syndrome type A children over the 2-year study period.

Major pneumocephalus after lung resection.

We present the case of a 62-year-old woman with an advanced metastatic lung tumor that required palliative debulking. Perioperative placement of a surgical clip in the dura of the thoracic spinal cord caused a dural breach, which ultimately caused a pneumocephalus. An awareness of this association is important, especially in patients undergoing thoracic resections. We also describe our approach to the management of this condition.

Acute effects of a single session of aerobic exercise with or without weight-lifting on bone turnover in healthy young women.

This study aimed to investigate the acute effects of exercise on bone turnover and to determine whether brisk walking with or without weight-lifting makes a difference on bone metabolism. Nine healthy women performed two exercise bouts: brisk walking on a treadmill for 30 min (E), and similar exercise carrying 5 kg of weight in a backpack (WE). Serum parathyroid hormone (PTH), osteocalcin (OC), calcitonin (CT), procollagen type 1 carboxy terminal propeptide (PICP), procollagen type 1 amino terminal propeptide (PINP), type 1 collagen carboxy terminal telopeptide (ICTP), total alkaline phosphatase (ALP), and urine deoxypyridinoline (D-Pyr) levels were studied. Resting values served as control. Significant variances were observed only in serum ALP and PTH values. Variances in ALP values within subjects after exercise were statistically significant (analysis of variance in repeated measurements [AVRM], P=0.000). E caused a significant decrease, while WE caused a significant increase in ALP values at the 24th h (Bonferroni pairwise comparisons tests [BPC t-test]: P=0.028, P=0.000, respectively). Variances in PTH values within subjects after exercise were statistically significant (AVRM, P=0.029), while diurnal variation was not significant (P=0.981). E caused significant alterations in PTH levels (an increase at the 30th min, turned towards baseline at the 45th min) (BPC t-test, P=0.007). WE also caused alterations in PTH levels, though insignificant (BPC t-test, P=1.00). Brisk walking for 30 min has stimulating effects on bone turnover by various mechanisms without any additive effect of weight bearing.

Detection of stent restenosis in single vessel CAD: comparison of 201Tl and gated 99mTc-MIBI SPECT.

BACKGROUND AND AIM: After successful percutaneous transluminal coronary angioplasty (PTCA), stent restenosis is observed in up to 40% of patients during the first year. The aim of this study was to determine the value of myocardial perfusion studies (MPSs) in the detection of stent restenosis in a symptomatic patient cohort. METHODS: A total of 80 patients without prior myocardial infarction (MI) and who underwent one-vessel PTCA with stent implantation were included to study. The diagnostic accuracy of two study protocols, Tl single photon emission computed tomography (SPECT) (38 patients) and rest-stress same day gated Tc sestamibi (MIBI) SPECT (42 patients), were compared. MPS data were visually evaluated by two experienced observers and stress induced perfusion defects with reversibility at rest was considered as restenosis. In gated MIBI data the wall motion (WM) and ejection fraction (EF) were also noted. The diagnostic value of a semiquantitative method based on 20 segment model and summed stress scores (SSSs) and summed difference scores (SDSs) were also tested. Results of MPSs were compared with control coronary angiography (CA) in all patients and agreement was defined as the kappa value (kappa). RESULTS: The average time between stent implantation and MPS was 8.9 +/- 2 months. Restenosis was detected in 58% of patients in CA. No significant differences were observed regarding age, gender, achieved exercise levels, vascular territorial distribution of lesions, imaging time interval after PTCA and degree of restenosis between Tl and gated MIBI groups. MPSs identified stent restenosis in 41 of 47 patients (sensitivity, 87%; specificity, 82%; accuracy, 85%; kappa=0.69). Four of six occluded stents that could not be detected in MPSs revealed intermediate degree stenosis (50-70%). Sensitivity, specificity and accuracy were not significantly different but better for gated MIBI group when compared to Tl (sensitivity, 90-83%; specificity, 85-80%; accuracy, 88-82%). Semiquantitative evaluation using SSS and SDS reached lower sensitivity than qualitative evaluation (MIBI, 90% vs 69%; Tl, 83% vs 72%) but higher specificity (MIBI, 85% vs 92%; Tl, 80% vs 100%) for both tracers and SSS were significantly correlated with occlusion degree (r=0.69). EF values calculated from the gated MIBI study were also inversely correlated with occlusion degree (r=0.55) and significantly different in patients with occluded stents (P<0.001). Agreement with CA for both tests were adequate (kappa=0.73, for MIBI; and kappa=0.63, for Tl). CONCLUSION: Semiquantitative evaluation of MPSs using SSS may enhance diagnostic specificity in the detection of stent restenosis. Both Tl and gated MIBI studies accurately detected stent restenosis. The gated MIBI method has advantages of WM analysis and evaluation of EF.

Tc-99m-HMPAO SPECT in the diagnosis of brain death in children.

BACKGROUND: The diagnosis of brain death is based on both clinical and laboratory findings. However, diagnosis of brain death is still contentious and reliable tests are required. Early recognition and declaration of the diagnosis is the main goal, which is important for discontinuation of life support and organ donation for transplantation. In order to achieve this goal, competent diagnostic procedures should be performed. In this paper the authors review the diagnosis of brain death in eight children from different age groups, with an emphasis on factors concerning the reliability, use and appropriate application time of Tc-99m-HMPAO single photon emission computed tomography (SPECT) in early diagnosis in infants and newborns. METHODS: Eight patients who fulfilled the clinical criteria of brain death underwent Tc-99m HMPAO SPECT and electroencephalogram (EEG) monitoring. RESULTS: All patients had electrocerebral silence on EEG recordings. Six patients showed lack of perfusion in cerebrum in their first SPECT, however, newborns needed a second image for a confirmed diagnosis. CONCLUSION: In infants, SPECT has a high reliability for confirmed diagnosis of brain death; however, in newborns the application time is important for an accurate diagnosis.

Gastric emptying in patients with vitamin B(12) deficiency.

The clinical presentation of patients with vitamin B(12) deficiency varies in a spectrum ranging from haematological disorders to neuropsychiatric diseases. In rare cases, orthostatic hypotension, impotence, constipation and urinary retention have been attributed to autonomic nervous system dysfunction due to vitamin B(12) deficiency. The aim of this study was to evaluate the effect of vitamin B(12) deficiency on autonomic nervous system function by studying gastric emptying times ( T(1/2)). Twenty patients with newly diagnosed vitamin B(12) deficiency and 12 control patients with gastritis and normal vitamin B(12) levels were enrolled in this study. Gastroduodenoscopy, endoscopic biopsy, histopathological evaluation of the biopsy specimens and radionuclide gastric emptying studies were performed. After vitamin B(12) replacement therapy for 3 months, radionuclide gastric emptying studies were repeated. Mean gastric emptying T(1/2) in patients before and after treatment and in controls were 103.83+/-48.80 min, 90.00+/-17.29 min and 74.55+/-8.52 min, respectively. The difference in mean gastric emptying T(1/2) between patients before treatment and controls was statistically significant ( P<0.01). The statistically significant difference persisted after vitamin B(12) treatment ( P<0.05), though mean gastric emptying T(1/2) was somewhat shorter. There were no positive or negative correlations between gastric emptying T(1/2) and the following parameters: haemoglobin, vitamin B(12) level and Helicobacter pylori positivity. In conclusion, gastric emptying T(1/2) was prolonged in patients with vitamin B(12) deficiency and this prolongation was not corrected after vitamin B(12) replacement therapy. Although autonomic nervous system dysfunction due to vitamin B(12) deficiency rarely gives rise to clinical manifestations, latent dysfunction demonstrated by laboratory tests seems to be a frequent phenomenon. The level of vitamin B(12) does not correlate with the degree of autonomic nervous system dysfunction measured by radionuclide gastric emptying studies.