Massive Tibial Bone Regeneration with Autologous Peripheral Blood Stem Cells using Ilizarov Bone Transport: A Case Report.

This is a case report of a Gustilo-Anderson Type IIIB comminuted open right tibial fracture with massive bone loss, complicated by methicillin-resistant Staphylococus aureus (MRSA) infection. Non-viable and contaminated bony fragments were removed and infected bone resected. Soft tissue coverage and antibiotics were effective against the MRSA infection. A unifocal bone transport with the Ilizarov method regenerated 13cm of the missing tibia. Autologous peripheral blood stem cells (PBSC) injections into the osteogenesis site boosted bone regeneration and consolidation with a shortened Bone Healing index (BHI) of 23 days/cm.

Comparison between use of neuromuscular blocking agent and placebo with the intubating laryngeal mask airway.

INTRODUCTION: The intubating laryngeal mask airway (ILMA) is a specially-designed airway device that can be used for endotracheal intubation without direct laryngoscopy. The advantage of this device is that it allows blind endotracheal intubation with a predictably high success rate. The use of neuromuscular blocking agents in facilitating the use of the ILMA has been investigated in the Western population with a quoted successful intubation rate of 88-96 percent. This randomised, double-blind study aimed to see if the use of neuromuscular blocking agent is necessary for successful intubations. METHODS: A total of 150 patients, rated categories 1 and 2 on the American Society of Anesthesiology Physical Status Classification System, were induced with propofol 2.5 mg/kg and fentanyl 2 microg/kg. After insertion of the ILMA, the patients received either saline or 0.6 mg/kg of rocuronium. After 90 seconds, tracheal intubation was attempted using the specially-designed silicon endotracheal tube. In addition to the success rate of intubation, the incidence of complications was also recorded. RESULTS: The success rate for tracheal intubation within three attempts was 93.3 percent for the saline group and 92.0 percent for the rocuronium group; this was statistically insignificant. The time to securing the airway was 11.5 seconds for the saline group, compared to 10.0 seconds in the rocuronium group, but this was statistically insignificant. The incidence of coughing during insertion of the endotracheal tube was 42.7 percent in the saline group as compared to 1.3 percent in the rocuronium group (p-value is less than 0.001). 12 percent of the patients in the saline group moved during intubation, while none was reported to move in the rocuronium group (p-value is 0.003). These results compared favourably with rates quoted in studies conducted on Western populations. CONCLUSION: The intubating laryngeal mask airway-assisted intubation yields a high success rate, which was similar between the paralysed and non-paralysed patients, with no statistical significance. However, the non-paralysed patients were prone to coughing and movements during intubation, requiring supplemental propofol.

Severe pulmonary hypertension in a patient with bronchiectasis complicated by cor pulmonale and a right-to-left shunt presenting for surgery.

A patient with advanced bronchiectasis, severe pulmonary hypertension complicated by cor pulmonale and a right-to-left shunt at atrial level presented for sigmoid colectomy. We outline the potential perioperative problems of this situation, discuss the perioperative risks and describe our clinical approach. A total intravenous anaesthetic technique using midazolam, fentanyl, ketamine and rocuronium was used to minimize changes in pulmonary and systemic vascular resistance and not induce bronchospasm. Preoperative nebulized salbutamol and ipratroprium were given to prevent bronchospasm and adrenaline and noradrenaline were infused to maintain cardiac output and the balance between systemic and pulmonary vascular resistance.

Peripheral nerve blocks for lower limb surgery--a choice anaesthetic technique for patients with a recent myocardial infarction?

Peripheral nerve blocks are associated with minimal haemodynamic disturbance. It is perhaps ideal for high-risk surgical patients who cannot tolerate the adverse consequences of even the slightest attenuation of haemodynamic response. However, peripheral nerve blockade is often perceived to be time consuming and undependable as the sole anaesthetic. In this report, a 56-year-old man with severe sepsis and recent myocardial infarction presents for an urgent above knee amputation. We present the practical benefits of a combined sciatic-femoral nerve block on such a patient.

A case report of the use of magnesium sulphate during anaesthesia in a patient who had adrenalectomy for phaeochromocytoma.

INTRODUCTION: Patients with phaeochromocytoma have haemodynamic instability during adrenalectomy. CLINICAL PICTURE: A case showing major swings of blood pressure during tumour handling. TREATMENT: Magnesium sulphate infusion alone failed to prevent severe hypertension. OUTCOME: The patient had to be given phentolamine and sodium nitroprusside to control the severe hypertension. CONCLUSION: The greatest value of magnesium sulphate is in controlling catecholamine release at induction and intubation, and in association with other agents in controlling arrhythmias and hypertension during tumour handling.

Sudden profound hypoxaemia in the intensive care unit--a case report.

Acute hypoxaemia is a life-threatening emergency. Diagnosis of the exact aetiology maybe complicated by the presence of pre-existing lung conditions. A case report is presented of a non-intubated patient with a pre-existing lung tumour who developed sudden profound hypoxaemia 3 days after emergency abdominal surgery. Definitive aetiological diagnosis was delayed due to chest X-ray features suggestive of compression and erosion of tumour tissue into the airway. Emergency computerised tomography (CT) imaging however revealed mucous plugging leading to massive atelectasis as the main aetiology.

Preoperative versus postoperative pethidine for extraction of impacted third molars.

We have studied the pre-emptive analgesic effects of pethidine by comparing its analgesic effects given before or immediately after operation in a randomized, double-blind study of 40 patients undergoing removal of bilateral impacted third molars under general anaesthesia. Group 1 patients received pethidine 50 mg as a 1 ml injection 1 to 2 hours before operation and normal saline 1 ml intramuscularly immediately after surgery. Group 2 patients received normal saline 1 ml intramuscularly before operation and pethidine 50 mg as a 1 ml injection immediately after surgery. Outcome measures included perception of pain on a visual analogue scale (VAS), the number of patients who required postoperative pethidine, time to first postoperative pethidine injection and total dose of pethidine given. Four patients in group 1 compared to 8 in group 2 required postoperative pethidine but this was not statistically significant. The VAS scores, time to first postoperative pethidine injection and total dose of pethidine also did not differ significantly between the 2 groups. We concluded that preoperative administration of pethidine intramuscularly did not confer additional analgesic effects compared with a similar dose given after surgery.

Perioperative transfusion strategies: a national survey among anaesthetists.

A current concern in perioperative transfusion therapy is the balance between maintaining adequate haemoglobin level and yet avoiding unnecessary homologous blood transfusion. Strategies to minimise the perioperative use of homologous blood include redefining the traditional transfusion trigger of "10/30 rule", and the use of autologous transfusion therapy. Current recommendations for transfusion triggers advocate determining the "minimum acceptable haemoglobin level" for patients according to various other physiological or surgical factors. The current status of practice amongst anaesthetists in the above mentioned transfusion strategies was assessed using a national survey. An overall response rate of 59.4% was obtained. Results showed wide variation among respondents in their criteria used for preoperative and intraoperative transfusion. Recommendations on perioperative transfusion triggers made by various authors were also summarised. Autologous transfusion therapy was also not frequently practised-the reasons for this were identified. We concluded that in order to continually improve on the anaesthetic community's quality of perioperative care, continued education on the subject must be carried out. Certain practical issues also need to be addressed to facilitate the use of perioperative autologous transfusion therapy.

Propofol and postanaesthetic shivering.

Sixty ASA grade 1 unpremedicated patients scheduled for minor elective surgery were randomly allocated to receive general anaesthesia consisting of either propofol-nitrous oxide in oxygen or a conventional technique of thiopentone-isoflurane-nitrous oxide-oxygen. Baseline axillary temperature readings, duration of operation and intra-operative decrease in axillary temperature were similar in both groups. The patients who received propofol-nitrous oxide-oxygen anaesthesia had a significantly lower incidence of postanaesthetic shivering than the control group. A propofol-nitrous oxide-oxygen technique may be preferable when postanaesthetic shivering is deemed undesirable.

Total intravenous anaesthesia versus inhalational anaesthesia for dental day surgery.

Fifty young healthy and unpremedicated patients scheduled for removal of impacted teeth were randomly allocated to receive either total intravenous anaesthesia with propofol or conventional thiopentone/isoflurane/nitrous oxide anaesthesia. A double-blind postoperative assessment showed the former group to have a shorter reversal time and faster recovery of faculties, i.e. speech, memory as well as ability to sit up and walk without assistance (P < 0.01). There was no incidence of hypotension and of awareness in either group. The incidence of headache, nausea and vomiting was higher in the thiopentone/isoflurane/nitrous oxide group.

Is sedation without desaturation possible?

The correlation between the depth of sedation and the degree of oxygen desaturation was studied in 52 patients presenting for surgery under regional anaesthesia. After establishing successful regional anaesthesia, patients were sedated with incremental doses of intravenous midazolam. The various levels of sedation were scored from 0 to IV. Continuous pulse oximetry allowed for correlation of sedation and saturation. Each patient's presedation oxygen saturation served as the control value. This was compared with the saturation at sedation levels II, III and IV and was found to be significantly higher (p less than 0.001). There was also a significant drop in saturation as patients progressed from sedation level II to III (p less than 0.02) and from level III to IV (p less than 0.001). The incidence of saturation falling to less than 90% was 4.35%, 14.71% and 40% at sedation scores of II, III and IV respectively.

Morbidity from subarachnoid spinal anaesthesia--a prospective study on the post-operative morbidity from subarachnoid spinal anaesthesia.

A clinical survey was conducted on 274 patients who had surgery under subarachnoid spinal anaesthesia. The anaesthetic was performed with either a 23 gauge or 25 gauge needle. All patients were interviewed on the second and sixth post-operative days. Data on morbidity (especially post-dural puncture headache and backache) was collated and analysed with respect to needle gauge. Backache was the most common complaint (20.5%). Using the finer needle did not reduce this aspect of morbidity. Post-dural puncture headache on the other hand was significantly reduced by the use of the finer 25 gauge needle (from 12.3% to 4.9%).