Spinal Anesthesia is Associated with Lower Recurrence Rates after Resection of Nonmuscle Invasive Bladder Cancer.

PURPOSE: We sought to determine whether anesthetic type (general vs spinal) would influence cancer recurrence following transurethral resection of bladder tumors. MATERIALS AND METHODS: With institutional ethics board approval we examined the electronic medical records of all patients who underwent transurethral bladder tumor resection for nonmuscle invasive urothelial bladder cancer between 2011 and 2013 at a single tertiary care center. Followup information was gathered on all patients in December 2016. The time to first cancer recurrence and the incidence of cancer recurrence were the main outcome measures. RESULTS: A total of 231 patients underwent 1 or more transurethral bladder tumor resections between 2011 and 2013. Of the 231 patients 135 received spinal anesthesia and 96 received general anesthesia. On univariable analysis the 135 patients who received spinal anesthesia had a longer median time to recurrence than the 96 who received general anesthesia (42.1 vs 17.2 months, p = 0.014). As anticipated, adjuvant therapies and risk category were associated with recurrence rates (p = 0.003 and 0.042, respectively). On multivariable analyses incorporating a priori variables of nonmuscle invasive bladder cancer risk stratification and postoperative therapies the patients who received general anesthesia had a higher incidence of recurrence (OR 2.06, 95% CI 1.14-3.74, p = 0.017) and an earlier time to recurrence (HR 1.57, 95% CI 1.13-2.19, p = 0.008) than those who received spinal anesthesia. Anesthetic type was not associated with cancer progression or overall mortality. CONCLUSIONS: Patients who received spinal anesthesia had a lower incidence of recurrence and a delayed time to recurrence following transurethral bladder tumor resection for nonmuscle invasive bladder cancer. These findings should prompt large-scale prospective studies to confirm this association.

Retrograde Extrusion of Coronary Thrombus During Urgent Aortocoronary Bypass Surgery: A Case Report.

A 73-year-old man underwent urgent coronary artery bypass grafting after an acute myocardial infarction. An angiogram had revealed multivessel disease with a circumflex artery lesion suspected as the primary culprit. On separation from cardiopulmonary bypass, transesophageal echocardiography revealed a new mobile mass in the aortic root. Cardiopulmonary bypass was reinstituted and a large thrombus emanating from the left coronary ostium was surgically removed. We hypothesize that the thrombus had originated from coronary retrograde extrusion during venous grafting. This case illustrates an unusual source of emboli during coronary artery bypass grafting and emphasizes the importance of perioperative transesophageal echocardiography for the prevention of potentially catastrophic outcomes.

A Case Report: Establishing a Definitive Airway in a Trauma Patient With a King Laryngeal Tube In Situ in the Presence of a Closed Head Injury and Difficult Airway: "Between the Devil and the Deep Blue Sea".

Airway management in trauma is a crucial skill, because patients are at risk of aspiration, hypoxia, and hypoventilation, all of which may be fatal in the setting of increased intracranial pressure. The King Laryngeal Tube reusable supraglottic airway (King Systems, Noblesville, IN) allows for temporary management of a difficult airway but poses a challenge when an attempt is made to exchange the device for an endotracheal tube, often managed by emergency tracheostomy. We describe a novel fiberoptic, video laryngoscope-assisted approach to intubation in a difficult trauma airway with an in situ King Laryngeal Tube.

Periarticular Morphine-Induced Sphincter of Oddi Spasm Causing Severe Pain and Bradycardia in an Awake Patient Under Spinal Anesthesia: An Important Diagnostic Consideration.

Sphincter of Oddi spasm from opioids has been documented, presenting as severe epigastric pain and potentially overlooked in a differential diagnosis. We present a case of sphincter of Oddi spasm from periarticular morphine in a patient under spinal anesthesia, causing severe distress and treated effectively with glucagon. It is important for anesthesiologists using opioids to consider it as a cause of perioperative pain and be familiar with treatment as it may be refractory by conventional use of opioids for pain relief. It is also important to consider the systemic effects of periarticular absorption, as evident by our case.

An observational cohort study to assess glycosylated hemoglobin screening for elective surgical patients.

INTRODUCTION: Uncontrolled blood glucose is associated with a higher incidence of surgical site infections, greater utilization of resources, and increased mortality. Preoperative screening for diabetes in elective surgical patients is not routinely performed. The purpose of this study was to examine blood glucose control in a preoperative surgical population. METHODS: Following ethics approval, adults presenting to the pre-surgical screening clinic in preparation for elective surgery were recruited. Data collection included a self-administered questionnaire on diabetic risk factors and blood glucose testing, including glycosylated hemoglobin (HbA1c). Descriptive analyses were conducted. RESULTS: Seventy of the 402 participants (17.4%) had a previous diagnosis of diabetes (diabetics). Among those without a history of diabetes (n = 332 non-diabetics), 23.2% (n = 77) were considered very high risk for diabetes (HbA1c = 6.0-6.4%), and 3.9% (n = 13) had a provisional diagnosis of diabetes (HbA1c ≥ 6.5%). Fifty-six percent (n = 39/70) of diabetics had suboptimal glycemic control (HbA1c > 7.0%), and 51.3% (n = 20/39) of this subgroup presumed their blood sugars were reasonably or very well controlled. Fifteen percent (n = 2/13) of patients with a provisional diagnosis of diabetes (HbA1c ≥ 6.5%) had an elevated random blood sugar (RBS) (≥ 11.1 mmol·L(-1)), while 67% (n = 8/12) had an elevated fasting blood sugar (FBS) (≥ 7.0 mmol·L(-1)). Forty-two percent (n = 16/38) of suboptimally controlled diabetics (HbA1c > 7.0%) had an elevated RBS (≥ 11.1 mmol·L(-1)), and 86% (n = 31/36) had an elevated FBS (≥ 7.0 mmol·L(-1)). DISCUSSION: Many elective surgical patients are at risk for unrecognized postoperative hyperglycemia and associated adverse outcomes. Random blood sugar testing has limited value and HbA1c may be a more appropriate test for the preoperative assessment of diabetic patients.