A survey of inhalational anaesthetic abuse in anaesthesia training programmes.

This study aims to assess the prevalence and outcomes of inhalational anaesthetic abuse among anaesthesia training programmes. Online surveys were completed by chairpersons of academic anaesthesia training programmes in the United States. The response rate was 84% (106/126 programmes). Twenty-two percent of the departments had had at least one incident of inhalational anaesthetic abuse. Forty-eight percent (15/31) of the persons abusing inhalational anaesthetics were sent for rehabilitation. Only 22% (7/31) of those found to be abusing inhalational anaesthetics were ultimately able to return successfully to anaesthesia practice with sustained recovery. The mortality rate among individuals found abusing inhalational anaesthetics was 26% (8/31). The majority of the anaesthesia departments (97/104, 93%) did not have any pharmacy accounting of inhalational anaesthetics. This is the first published survey of inhalational anaesthesia abuse. Inhalational anaesthetic abuse should be considered in at-risk individuals or those with a history of substance abuse. The concern about substance abuse is not unique to American anaesthetists. Countries around the world deal with similar substance abuse issues.

Failure rate of frontal versus parietal approaches for proximal catheter placement in ventriculoperitoneal shunts: revisited.

Early studies on ventriculoperitoneal shunt malfunctions demonstrated that proximal catheter obstruction was the most common cause for shunt malfunction and choroid plexus was the primary culprit for catheter obstruction. Subsequently, several studies were performed using stereotactic and endoscopic guidance systems to assist with optimal placement of proximal shunt catheters. Surgeons collectively agree that optimum placement of the proximal catheter tip is away from choroid plexus in the frontal horn. To achieve this catheter placement, neurosurgeons typically choose a frontal or parietal approach. Two previous studies comparing parietal and frontal shunt failure rates in the pediatric population have different conclusions. Thus, we decided to compare proximal catheter failure rates of frontal versus parietal approaches on 117 patients (ages ranging from 1 month to 80 years) who had undergone ventriculoperitoneal shunt placement at our institution. Statistical analysis demonstrated a significantly higher malfunction rate in the patients less than 3 years of age and a lower overall malfunction rate in patients shunted for normal pressure hydrocephalus. Surprisingly, there was no significant difference between the two surgical approaches. Thus, we concluded after reviewing the literature, that regardless of the initial surgical approach, the most important variable in shunt malfunction appears to be the final destination of the catheter tip in relation to the choroid plexus.

Prophylaxis to avert exacerbation/relapse of multiple sclerosis in affected patients undergoing surgery. Surgical observations and recommendations.

To provide the neurological and neurosurgical communities with case evidence of postoperative multiple sclerosis (MS) relapse, literature review to support operative stress-induced relapse and recommendations for perioperative prophylaxis to prevent relapse in patients undergoing surgery. Two case studies are presented with recommendations based on an extensive review of the medical literature and personal experience to support perioperative prophylactic suggestions. Both patients fully recovered to preoperative functional status after treatment. We now routinely implement perioperative prophylaxis to MS patients undergoing surgery at our institution with no complications to date. Perioperative prophylaxis in patients with MS undergoing surgery can prevent relapse. It is of utmost importance that the surgical community realizes that prophylactic treatment is available and should be utilized during elective and emergent surgical situations.

Sudden death secondary to fulminant intracranial aspegillosis in a healthy teenager after posterior fossa surgery: the role of corticosteroids and prophylactic recommendations.

Postoperative complications from corticosteroids in neurosurgical patients are not uncommon. Too often the deleterious immunosuppressive effects of corticosteroids are overlooked in neurosurgery patients and can lead to serious and lethal infections. EXPERIMENTAL DESIGN: case report of a 16-year-old healthy male who presented for elective resection of a recurrent juvile pilocytic astrocytoma of the posterior fossa 4 years after initial resection. SETTING: major University institutional practice. INTERVENTION/RESULTS: a standard suboccipital craniotomy with gross total resection. Postoperatively, the patient suffered from posterior fossa syndrome and diminished gag reflex requiring nasogastric feeds with progressive improvement. While awaiting transfer to a rehabilitation center on postoperative day 12 he suffered a sudden temperature spike followed by neurological decline. A stat computed tomography scan of the brain revealed a diffuse miliary process with severe cerebral edema. Sputum and cerebrospinal fluid cultures identified Aspergillus. Despite immediate therapy to combat the malignant cerebral edema, the patient died within 24 hours of onset of the symptoms. Corticosteroids are used routinely in neurosurgery to combat cerebral edema without much consideration for the immunosuppressive effects. This case demonstrates how the immunosuppressive effects of corticosteroids can lead to a fulminant lethal fungal infection. Neurosurgeons should be aware of the anticatabolic medications now available to combat the deleterious side effects of corticosteroids.

Isolated intracranial infection with Mycobacterium avium complex.

UNLABELLED: Mycobacterium avium-M. complex (MAC) has been linked to devastating respiratory and systemic illnesses in patients, especially in those who are immunosuppressed. The purpose of this study is to describe a case of isolated central nervous system (CNS) infection with MAC. This is a single case report of a patient with isolated intracranial mycobacterial infection. SETTING: the patient was treated and the immunohistochemical investigations were undertaken at the National Institutes of Health in Bethesda, Maryland, USA. INTERVENTION: the patient initially was treated with a cocktail of antimycobacterial medications. However, because his disease was refractory, he underwent a suboccipital craniotomy and evacuation of his cerebellar mass. The patient was determined to have a low production of interferon-gamma (INF-gamma) and tumor necrosis factor-alpha (TNF-alpha) when compared to normal values. Despite extensive radiographic imaging studies and biopsies, there was no evidence of another focus of MAC infection in this patient. We conclude that intracranial infectious lesions in patients such as ours should be treated with conventional systemic antibiotic regimens as the first-line of therapy. We suggest neurosurgical intervention in medically refractory cases of intracranial infections.

The role of surgical placement and pump orientation in intrathecal pump system failure: a technical report.

Intrathecal pump catheter complications are the most common cause of failure in drug delivery. A previous report has documented that intra-abdominal positioning of the intrathecal pump may predispose the pump-catheter neck to premature catheter breakdown and leakage. Based on this report, we reviewed over 100 intrathecal pump cases to determine the frequency of malpositioning and its role in the pathogenesis of catheter failure. We found three specific cases where a 'fulcrum effect' occurred due to intra-abdominal positioning of the pump predisposing the catheter to breakdown. This study demonstrates that intra-abdominal placement of the pump can predispose the catheter to failure/breakdown and that surgeons should attempt to place the pump catheter neck in a superiomedial position, distant from any bony prominences, to prevent the 'fulcrum effect' on the pump-catheter neck junction and reducing the likelihood of either internal or external compressive forces.