Gossypiboma during orthognathic surgery: A case report.

INTRODUCTION: Dislodgment of nasopharyngeal temperature probes and/or unretrieved device fragments (UDFs) or gossypibome at a patient's hypopharynx is rare complication after orthognathic surgery that may occur as a result of surgical manipulation or may be a consequence of factors related to the insertion and handling of the probe after extubation. However, the exact mechanism of this complication is unknown. To the best of our knowledge, this is the 1st reported case of a missing temperature probe after orthognathic surgery. CASE PRESENTATION: We report the case of a patient who suffered from dislodgment of a 12-cm temperature probe after orthognathic surgery. The surgery was uneventful. At the end of the surgery, the probe was believed to have been completely removed from the nasal cavity. The nasopharyngeal cavity was visually inspected while the patient was still under anaesthesia and the trachea was still intubated. Extubation was successful, and the patient was moved to the recovery area. The patient was discharged from the hospital one day after resuming an oral fluid diet. At the follow-up visit on the 4th postoperative day, the patient presented with mild symptoms of a sore throat and cough. At the follow-up visit in the 3rd postoperative week, the patient reported one episode of vomiting and severe coughing, and the patient ultimately retrieved the 12-cm temperature probe from her mouth. DISCUSSION: After conducting a systematic literature review, we discuss surgical cases involving UDFs or gossypiboma. We also describe changes in our clinical practice after this event, and we envision that these modifications will have a positive influence on patient care. We believe that alternative routes for inserting temperature probes with covers would be suitable for orthognathic surgery. CONCLUSION: Vigilance should be maintained during patient extubation by both teams (surgeons and anaesthetists) to assure that part of the probe always remains visible outside the oral/nasal cavity as well as complete removal of the device to avoid this life-threating complication.

Effects of terlipressin infusion on blood loss and transfusion needs during liver resection: A randomised trial.

BACKGROUND: Blood loss and perioperative blood transfusion requirements affect the long-term survival after liver resection for malignant tumours. Terlipressin is a synthetic vasopressin analogue with relative specificity for the splanchnic circulation where it causes vasoconstriction with subsequent reduction of blood loss during abdominal surgeries. We tried to examine the impact of terlipressin on blood loss and blood transfusion needs during liver resection. METHODS: In this randomised, double-blind placebo-controlled trial 84 patients scheduled for major liver resections were randomly assigned to receive either terlipressin at the onset of surgery as an initial bolus dose of (1 mg over 30 minutes) followed by a continuous infusion of 2 µg/kg/h throughout the procedure (Terlipressin group) or the same volume and rate of 0.9% saline (Placebo group).The primary outcome was the amount of intra-operative blood loss. RESULTS: The mean (SD) of the amount of intra-operative blood loss was 1351 (887) in the terlipressin group versus 1892 (889) mL in the placebo group (P = 0.006). Thirteen (30%) patients received blood transfusion in the terlipressin group compared with t27 (64.2%) in the placebo group (P = 0.002) with a statistically significant difference in the median (range) number of the transfused units of packed RBCs [0 (0-5) units and 1 (0-6) units in the two groups respectively; P = 0.001]. CONCLUSION: Terlipressin infusion during major liver resection was associated with less bleeding compared to placebo. More studies are required to confirm our results especially in patients with normal portal pressure.

Esmolol versus dexmedetomidine in scoliosis surgery: study on intraoperative blood loss and hemodynamic changes.

BACKGROUND: Surgical correction ofscoliosis carries significant blood loss and needs for blood transfusion with its inherent risks and cost. The aim of this double-blind, randomized, controlled study was to compare the effects of esmolol or dexmedetomidine on intraoperative blood loss, anesthetics consumption, intra operative hemodynamic and effects on spinal cord monitoring in patients undergoing scoliosis surgery. METHODS: After obtaining institute review board approval and written informed consent, 60 adolescents (ASA physical status I-II), 14-18-year of age scheduled for posterior spinal fusion scoliosis surgery were enrolled in the study. Using computer generator software patients were randomly allocated to receive either saline as a control (group C), esmolol (Group E) or dexmedetomidine (Group D). RESULTS: There was a significant reduction in blood loss in patients who received esmolol and dexmeditomidine compared to control it was as follow; in control group 782+/-86.4 ml (P < or = 0.001), esmolol group 667+/-145.2 ml (P < or = 0.001) and dexmeditomidine group 465 +/-115.3 ml (P < or = 0.001). Mean intraoperative total fentanyl and propofol consumption in the esmolol group was significantly higher than in the dexmedetomidine group, this was especially dramatic for the dexmedetomidine group where the propofol consumption was twice less P < or = 0.001. There was no significant effect seen in SSEPs (amplitude or latency) but there was isolated decrease in motor evoked potential (MEP) amplitude which was within acceptable range that was seen in 6 patients receiving dexmeditomidine at a dose of 0. 7 micro g/Kg/H. CONCLUSION: Both esmolol and dexmedetomidine, added to anesthetic regimen, provided an effective and well-tolerated method to reduce the amount of blood loss in patients undergoing scoliosis surgery. dexmedetomidine, was associated with plonoged extubation and recovery times.

Lactate and acid base changes during laparoscopic cholecystectomy.

BACKGROUND: The observation of hemodynamic and metabolic impairment related to CO2 pneumoperitoneum and postoperative mesenteric ischemia reports following laparoscopic procedures have raised concern about local and systemic effects of increase intraabdominal pressure during laparoscopic procedures. The present study aims to evaluate the metabolic and acid base responses of using high pressure versus low pressure pneumoperitonium in patients undergoing laparoscopic cholecystectomy in a prospective randomized clinical trial. PATIENTS AND METHOD: 20 ASA I-II patients scheduled for elective laparoscopic cholecystectomy were randomly allocated to one of two study groups; high pressure pneumoperitoneum 12-14mmHg (HPP, n=10) versus low pressure pneumoperitoneum 6-8mmHg (LPP, n=10) undergoing laparoscopic cholecystectomy. Arterial blood gases and lactate levels were determined after induction of anesthesia (before pneumoperitonium), then after 10 min, then 30 min after insufflations and at the end of surgery and 1 hour postoperatively. Nurses in recovery unit reported pain assessment starting postoperatively until 3 hours on a 10mm VAS (0-10). Statistical significant was established at P<0.05. RESULT: Bicarbonate was significantly (P>0.0412) lower in high pressure group at 30 min and 60 min after insufflations. In high pressure group lactate levels increased significantly as compared to low pressure group, (at 30 minutes after the establishment of abdominal pneumatic inflation P<0.006 and remained significantly increased (P<0.001) until the end of surgery and one hour thereafter) (P<0.001). The mean postoperative pain score during second hour (VAS) at HPP group was 7.4 +/- 1.17 which is significantly (P < or = 0.006) higher than pain score in LPP group 5.0 +/- 1.886. Shoulder tip pain was reported in 3 patients in the high pressure group and only one patient in the lower pressure group. CONCLUSION: High-pressure pneumoperitonium causes statistically significant elevation in the arterial lactate level intraoperatively until one hour post operatively. It also causes higher pain score and shoulder tip pain.

The effect of prone position on respiratory mechanics during spinal surgery.

OBJECTIVE: To study the effect of prone position on respiratory mechanics during spine surgery. DESIGN: Prospective study. SETTING: Elective spine surgery at a university hospital. PATIENTS: 12 ASA physical I & II with no coexisting cardiorespiratory disease undergoing cervical or lumbar laminectomy under general anesthesia in prone position. MEASUREMENTS: Ten min after induction of general anesthesia and endotracheal intubation, while patients were in supine position, the following measurements were taken using anesthesia delivery unit (Datex Ohmeda type A_Elec, Promma, Sweden): peak airway pressure (Ppeak), peak plataeu pressure (Pplat), peak mean pressure (Pmean) and dynamic lung compliance (DLC). The same measurements were recorded 10 min after placing patients into prone position. At the end of surgery and 5 min after turning the patients supine and before tracheal extubation, the same measurements were again recorded. The results expressed as means +/- sd. One way ANOVA was used for analysis of differences in the data before, during prone position and after turning patients supine at the end of the procedure. For all comparisons p < 0.05 was considered significant. RESULTS: During prone position there was significant reduction in DLC and significant increase in airway pressures. CONCLUSION: We conclude that turning the patients form supine to prone position during anesthesia for spine surgery caused significant decrease of DLC and significant increase of airway pressure.