Pressure-controlled inverse ratio ventilation using laryngeal mask airway in gynecological laparoscopy.

BACKGROUND: It is well documented that pressure-controlled ventilation (PCV) improves oxygenation and ventilation compared to volume-controlled ventilation and reduces peak airway pressure in gynecological laparoscopy. PCV with moderately inversed inspiratory-expiratory (I: E) ratio can successfully recruit collapsed alveoli and has been proved to be beneficial in intensive care. We tested the hypothesis that altering the I: E ratio to 1.5:1 in PCV improves ventilation during gynecological laparoscopy using laryngeal mask airway (LMA). OBJECTIVE: To study pressure-controlled inverse ratio ventilation (PCIRV) with I: E ratio 1.5:1 as against PCV with I: E ratio 1:2 in gynecological laparoscopy with LMA using noninvasive parameters. MATERIALS AND METHODS: Intraoperative hemodynamics and side-stream spirometry recordings were noted in 20 consecutive patients undergoing major gynecological laparoscopy with LMA. Flexible LMA or LMA supreme were used depending on normal body mass index (BMI) or high BMI, respectively. RESULTS: REVERSING THE I: E ratio to 1.5:1 increased the tidal volume, mean airway pressures, and dynamic lung compliance significantly, all indicating better oxygenation at comparable peak airway pressures as against PCV with I: E ratio 1:2. There was no change in the end-tidal carbon dioxide. There was no auto-positive end expiratory pressure (PEEP) or change in the hemodynamics. CONCLUSION: REVERSAL OF I: E ratio with PCV can be beneficially used with LMA in laparoscopy.

Anesthesia concerns in laparoscopic myomectomy.

Recent advances in the practice of anesthsiology ensure that we move closer to our goal of zero morbidity. It is of critical importance that we couple our clinical expertise with the sophisticated monitoring equipment and get the best out of them.

Molecular characterization of rare bovine group A rotavirus G15P[11] and G15P[21] strains from eastern India: identification of simian SA11-like VP6 genes in G15P[21] strains.

During a surveillance study (November 2001-March 2005), one rare G15P[11] and two rare G15P[21] bovine group A rotavirus strains were detected in diarrhoeic calves in Eastern India. Sequence analysis of the VP8*, VP6, NSP4 and NSP5 genes of the G15P[11] strain confirmed its bovine origin. Although the NSP4 and NSP5 genes of the two G15P[21] strains were of bovine origin, their VP6 genes shared higher nucleotide and amino acid identities with simian strain SA11 (92.5-93.1% and 98.5-98.7%) than bovine strains (88.5-88.9% and 97-97.2%), and by phylogenetic analysis, exhibited clustering with SA11, distantly related to bovine strains. All these pointed towards a possible reassortment event of VP6 gene between bovine and simian (SA11-like) strains. Therefore, the present study provided molecular evidence for bovine origin of G15 strains and revealed a rare instance of genetic diversity in the bovine VP6 gene, otherwise conserved in group A rotavirus strains from cattle.

Parotid area sign: a clinical test for the diagnosis of fluid overload in hysteroscopic surgery.

STUDY OBJECTIVE: To describe the clinical test parotid area sign, which is used to assess fluid absorption during resectoscopic surgery and to compare the test with volumetric fluid balance method with respect to its ability to detect fluid overload. DESIGN: Historical cohort study (Canadian Task Force classification II-1). SETTING: Tertiary endoscopy center. PATIENTS: Eighty-six women who underwent resectoscopic surgery between 1999 and 2004 at our center. INTERVENTION: The volumetric fluid balance method was used to evaluate glycine absorption (glycine deficit) during the surgery. A flexometallic ruler was placed on the left cheek of the patient between 2 fixed points: the midpoint of the philtrum and a point on the mastoid prominence, and this distance (philtrum-mastoid prominence distance) was measured at the beginning of every 3 minutes during, and at the end of the procedure. MEASUREMENTS AND MAIN RESULTS: Eighty-six patients were divided into 2 groups: Group A, which included patients with absorption less than 1000 mL as measured by the volumetric method; and Group B, which included patients with absorption of 1000 mL or more. The results of the parotid area sign test in the 2 groups were compared. The 2 groups were comparable with respect to the age, weight, preoperative measured philtrum-mastoid prominence distance, and hospital stay. The median (and average absolute deviation) operating time in group A (15 minutes [and 6.79]; range 8-60 minutes; 95% CI of the median, 15-20 minutes) was significantly lower than the median (and average absolute deviation) operating time in group B (25 minutes [and 8.96]; range 9-60 minutes; 95% CI of the median, 20-25 minutes; p <.001). The mean postoperative philtrum-mastoid prominence distance measured in patients of group A (14.23 +/- 0.396 cm [range 14-16 cm, 95% CI 14.10-14.36 cm]) was significantly lower than that in group B [14.76 +/- 0.622 cm (range 14-17 cm, 95% CI 14.58-15.12 cm]; p <.001). By paired t test, the change in the philtrum-mastoid prominence distance after surgery as compared with the value before surgery in each patient was found to be insignificant in group A (p =.86). However, it was found to be significant in group B (p <.001). The increase in the measured philtrum-mastoid prominence distance (i.e., postoperative measurement minus the preoperative measurement) in each patient after surgery was significantly more in group B (mean +/- SD, 0.54 +/- 0.362 cm [range 0-2 cm, 95% CI 0.43-0.65 cm]) than that in group A (mean +/- SD, 0.03 +/- 0.091 cm [range 0-0.4 cm, 95% CI 0.008-0.06 cm]; p <.001). The correlation coefficient for the increase in the philtrum-mastoid prominence distance as the glycine deficit increased in the 2 groups considered together was significant (r = 0.937, p <.01). The partial regression coefficient b value for the effect of duration of surgery while controlling for the effect of fluid deficit was 0.008 (p <.001), and the b value for the effect of fluid deficit while controlling for the effect of duration of surgery was 0.437 (p <.001). The regression coefficient r value (0.727) for the goodness of the fit of the regression line to the data sets was also significant (p <.001). The sensitivity of the test with respect to the volumetric fluid balance is 97.8% (95% CI, 87.28%-99.88%) and specificity is 92.3% (95% CI, 78.03%-97.99%). The negative predictive value is 97.30% (95% CI, 84.19%-99.85%) and positive predictive value is 93.87 (95% CI, 82.13%-98.40%). The conventional positive likelihood ratio for the test is 12.72 (95% CI 4.28-37.77). The conventional negative likelihood ratio is 0.023 (95% CI 0.003-0.16). CONCLUSION: The parotid area sign is a simple, effective, and easy-to-perform test (in real time continuously) that requires minimal equipment or training. It supplements the volumetric fluid balance method in the detection of fluid overload (1.5% glycine) during resectoscopic surgery. It may also enable us to detect fluid overload when volumetric fluid balance method fails to detect extraneous losses caused by spillage.