Modified Mallampati Class Rating Before and After Cesarean Delivery: A Prospective Observational Study.

BACKGROUND: The modified Mallampati classification (MMC) provides an estimate of the tongue size relative to the oral cavity size, and is a usual screening tool for predicting difficult laryngoscopy. Previous studies have indicated an increase of MMC during the progression of pregnancy, but there is no comprehensive study in pregnant women undergoing cesarean delivery. The primary aim of this study was to evaluate the MMC before and after cesarean delivery. METHODS: This is a prospective observational study of 104 women who underwent cesarean section. MMC, thyromental distance, neck circumference, and upper lip bite test were evaluated at 4 different time points: during the pre-anesthetic visit (T0) and at 1 (T1), 6 (T2), and 24 (T3) hours after delivery. Factors evaluated for their predictive validity included gestational weight gain, operation time, amount of intravascular fluids, oxytocin dosage, and blood loss. The correlation between each factor and the MMC classification was tested by logistic regression. RESULTS: From 104 participants, 59.6% experienced Mallampati class changes. The proportions of patients classified as Mallampati III and IV at different time points were: T0 = 48.1% (MMC III only), T1 = 75.0%, T2 = 80.8%, and T3 = 84.6%, respectively. Gestational weight gain, duration of surgery, anesthetic method, blood loss, oxytocin dosage, or amount of intravenous fl uid were not correlated with the MMC change. CONCLUSION: The number of patients with initial Mallampati III was high. In addition, a significant increase in MMC occurred after cesarean delivery. The data confirm the particular risk status of women undergoing cesarean delivery particularly regarding airway anatomy.

Regional Catheters for Postoperative Pain Control: Review and Observational Data.

CONTEXT: Perioperative analgesia is an essential but frequently underrated component of medical care. The purpose of this work is to describe the actual situation of surgical patients focusing on effective pain control by discarding prejudice against 'aggressive' measures. EVIDENCE ACQUISITION: This is a narrative review about continuous regional pain therapy with catheters in the postoperative period. Included are the most-relevant literature as well as own experiences. RESULTS: As evidenced by an abundance of studies, continuous regional/neuraxial blocks are the most effective approach for relief of severe postoperative pain. Catheters have to be placed in adequate anatomical positions and meticulously maintained as long as they remain in situ. Peripheral catheters in interscalene, femoral, and sciatic positions are effective in patients with surgery of upper and lower limbs. Epidural catheters are effective in abdominal and thoracic surgery, birth pain, and artery occlusive disease, whereas paravertebral analgesia may be beneficial in patients with unilateral approach of the truncus. However, failure rates are high, especially for epidural catheter analgesia. Unfortunately, many reports lack a comprehensive description of catheter application, management, failure rates and complications and thus cannot be compared with each other. CONCLUSIONS: Effective control of postoperative pain is possible by the application of regional/neuraxial catheters, measures requiring dedication, skill, effort, and funds. Standard operating procedures contribute to minimizing complications and adverse side effects. Nevertheless, these methods are still not widely accepted by therapists, although more than 50% of postoperative patients suffer from 'moderate, severe or worst' pain.

Allogeneic red cell transfusion and its influence on relevant humoral and cellular immunological parameters: A prospective observational trial.

BACKGROUND: It is assumed that transfusion of allogeneic red cells is associated with increased peri-operative mortality and morbidity. Also assumed is the theory of transfusion-related immunomodulation. OBJECTIVE: The aim of this study was to investigate the hypothesis that red cell transfusion specifically leads to an immunological response in surgical patients. DESIGN: Prospective observational study. SETTING: Departments of Orthopedic Surgery and Anaesthesia, University Hospital, Thailand. PATIENTS: Low-risk, noncancer patients, aged 18 to 75 years undergoing elective major spine surgery, with and without red cell transfusion therapy. INTERVENTIONS: Blood specimens were withdrawn four times (prior to surgery and on days 1, 3 and 5). MAIN OUTCOME MEASURES: Assessment of immunocompetent cells and cytokines in transfused and nontransfused patients using flow cytometry and multiplex ELISA. RESULTS: From a total of 78 patients, 61 met the requirements and were analysed in three groups: 19 with no transfusion and 26 and 16 transfused intra-operatively and on day 1 or 2, respectively. No patient experienced peri-operative haemorrhage. Postoperative infection or thrombosis occurred in 5.5% of nontransfused patients and 16.6% of transfused patients; the difference was not significant. There was no significant immunomodulatory effect of red cell transfusion: of 45 immunological parameters, only five little-relevant cytokines were significantly affected, although slightly and nonspecifically. CONCLUSION: Our data indicate that red cell transfusion alone does not create an immunological response in otherwise healthy surgical patients. Our findings do not generally contradict the transfusion-related immunomodulation phenomenon, which has, however, primarily been observed in patients with an already weakened or procedure-deteriorated immune system, such as from malignant disease, significant comorbidity, extensive abdominal/thoracic surgery and cardiopulmonary bypass. TRIAL REGISTRATION: The study was registered on 15 May 2014, before enrolment of the first patient, at www.ClinicalTrials.gov, NCT02140216.

A rare case of acute kidney injury and anemia induced by hypercalcemia.

Hypercalcemia may result in acute kidney injury (AKI) and arterial hypertension. Anemia as a consequence of this constellation is nowhere described. A female patient underwent total thyroidectomy in 2007, since then being under continuous daily medication with 100 µg thyroxin, 1.6 g calcium and 1.0 µg alfacalcidol. In 2017, after accidentally overdosing alfacalcidol fourfold for several weeks leading to massive hypercalcemia (plasma calcium level 16.7 mg/dL), the otherwise healthy patient developed symptoms of AKI, such as serum creatinine 2.48 mg/dL, plus severe hypertension and acute anemia (hemoglobin concentration 10.2 g/dL). After cessation of calcium and alfacalcidol medication for 9 days, hypercalcemia and AKI symptoms and anemia recovered within 14 and after 62 days, respectively. The patient is currently free of complaints and has been sufficiently treated with half of the yearslong pre-event calcium/alfacalcidol dose. In conclusion, hypercalcemia with consecutive AKI after vitamin D overdose can occur asymptomatically. The treatment does not compulsorily include washout by hyperhydration and diuretics. AKI may lead to anemia, possibly caused by the deterioration of the release of erythropoietin.

Pain after Major Craniotomy in a University Hospital: A Prospective Cohort Study.

BACKGROUND: Pain after major craniotomy has been believed to be less severe than the other operations. OBJECTIVE: To determine the incidence and risk factors of moderate to severe pain after major craniotomy. MATERIAL AND METHOD: This is a prospective observational study in a neurosurgical intensive care unit and wards of a university, tertiary hospital. After institutional IRB approval, patients undergoing major craniotomy during May 2011-August 2012 were interviewed preoperatively and 24 and 48 hours postoperatively. Demographic data, preoperative anxiety scores, operative data and postoperative pain characteristics were recorded. RESULTS: Two hundred and eighty patients completed the study. The incidence of moderate to severe pain was 75%. Mean pain score during 24 and 48 hours were 5.5 ± 2.7 and 3.5 ± 2.6, respectively. Univariate analysis identified age under 45 years and perioperative steroid therapy as predictors of moderate to severe postoperative pain. Using multivariate analysis, only age under 45 years was a significant risk factor. Patients' satisfaction scores were good in both mild and moderate to severe pain groups (9.49 ± 1.08 and 8.37 ± 1.76). During postoperative period, almost all of the patients received intravenous opioid and oral acetaminophen for pain treatment. No respiratory depression occurred, but postoperative nausea and vomiting occurred in 51.7% and pruritus in 23.6%. CONCLUSION: Incidence of pain after craniotomy was high especially in younger age group, which is not in accordance with all similar reports. However we believe pain management after major craniotomy in our hospital requires improvement.

Paravertebral Catheter for Three-Level Injection in Radical Mastectomy: A Randomised Controlled Study.

INTRODUCTION: Paravertebral block (PVB) is an alternative to general anaesthesia (GA) for breast surgery. However, for extensive surgery multiple punctures are needed increasing the immanent risk of the method. The purpose of this study was to evaluate PVB via catheter and injections at three different levels. Primary outcome was the quality of postoperative analgesia, in particular, the number of patients requiring additional morphine. METHODS: In a randomised single blinded clinical study patients scheduled for breast surgery including axillary approach, were randomly allocated to different anaesthetic techniques, n = 35 each. Patients received either GA with sevoflurane or PVB with catheter at level Th 4. In PVB-patients a 1:2 mixture of bupivacaine 0.5% and lidocaine 2% with adrenaline was injected sequentially 10 ml each at three different levels. RESULTS: Complication-free catheter insertion was possible in all 35 scheduled patients. The need for postoperative analgesics was higher after GA compared to PVB (22 vs.14 patients); p = 0.056. Postoperative morphine consumption was 1.55 (GA) and 0.26 mg (PVB) respectively (p < 0.001). Visual rating score (VRS) for pain at rest and at movement was higher in GA patients on post anaesthesia care unit (PACU) as well as on the ward at 1-6 h and 6-12 h. Readiness for discharge was earlier after PVB (4.96 and 6.52 hours respectively). After GA the incidence and severity of postoperative nausea and vomiting (PONV) was higher, though not significantly. Patients' satisfaction was comparable in both groups. CONCLUSIONS: Three-level injection PVB via catheter for extensive mastectomy was efficient and well accepted. Using a catheter may enhance safety by avoiding multiple paravertebral punctures when extended spread of analgesia is required. TRIAL REGISTRATION: www.ClinicalTrial.gov NCT02065947.

Effects of a restrictive fluid regimen in pediatric patients undergoing major abdominal surgery.

OBJECTIVE: To investigate the effects of restrictive fluid regimen during major abdominal surgery in pediatric patients. BACKGROUND: In adults, a restrictive and goal-directed regimen as opposed to a liberal-fluid regimen results in better outcomes after various major surgical procedures. The different ratio of body fluid distribution in pediatric patients from those of adults may influence different needs of fluid. METHODS: This stratified, randomized, controlled trial was conducted in 25 pediatric patients (mean age <3 years) undergoing major abdominal surgery. Patients were allocated to two groups based on their perioperative fluid management. 'control group' received maintenance plus deficit plus interstitial space replacement plus ongoing loss, whereas 'restrictive group' had a similar treatment, but were given no interstitial space replacement. Intraoperative fluid resuscitation was guided by hemodynamics and base excess. Parameters recorded included hemodynamic variables, the volume and type of intravenous fluid, blood chemistry (including lactate, base excess, and electrolyte), chest X-ray, body weight, complications, and return of bowel function. RESULTS: Patients in control group needed significantly less additional fluid for resuscitation compared to restrictive group (0.62 ± 3.51 ml · kg(-1) · h(-1) vs 5.04 ± 4.16 ml · kg(-1) · h(-1) ; P = 0.012). In restrictive group, heart rates were higher (P = 0.012) and base excess showed more negative results (P = 0.049). There were no differences between the groups in terms of the total volume requirement, postoperative kidney function, chest X-ray, variation of body weight and the postoperative outcomes. CONCLUSIONS: Volume preload corresponding with an estimated interstitial space replacement was suitable for application to pediatric patients undergoing major abdominal surgery.

"Don juan-fracture" as a hint to aortic isthmus rupture.

We report a case of thoracic aortic rupture after blunt trauma in a 23-year-old male patient. The initial investigation found no external injury or bleeding, only a slightly widened mediastinum and a broken left calcaneus. Abdominal lavage was negative, biochemistry was normal, and breathing and oxygenation were not compromised. When changing his position during diagnostics, the patient all of a sudden developed cardiac arrest and typical signs of hypovolemic shock. An immediate sternotomy was done without any further diagnostics on suspicion of aortic isthmus injury. A circular avulsion at the ligamentum arteriosum was found as assumed and repaired under cardiopulmonary bypass. The patient left the hospital for rehabilitation after 12 days in adequate health status. Biodynamics of blunt trauma after high-speed frontal impact and the relationship between calcaneus fracture, called "Don-Juan fracture," and aortic rupture at the site of ligamentum arteriosum are discussed.

Predictors for complications in pregnant women with heart disease, a retrospective study.

OBJECTIVE: Evaluate the CARPREG score in predicting cardiac, obstetric, and neonatal complications in pregnant women with heart disease. MATERIAL AND METHOD: This was a retrospective study between 2002 and 2011 at a tertiary care center and included 175 pregnant women with heart disease. Maternal and neonatal outcomes were assessed using Cardiac in Pregnancy Score (CARPREG), which included NYHA-class, systolic ejection fraction, left ventricular obstruction, and history of cardiac events. RESULTS: Rheumatic heart disease (n = 116, 66.3%) was the predominant cardiac problem. CARPREG score was 0, 1, > 1 in 65.1%, 24.6%, and 10.3% pregnancies, respectively. Maternal cardiac events occurred in 27.4%. CARPREG score > or = 1 was associated with an increased rate of cardiac events [odds ratio (OR) 6.76, 95% confidence interval (CI) 3.26 to 14.01]. Fetal complications occurred 24.4%. Neonatal birth weight < 2,500 g was associated with CARPREG score > or = 1 (OR 2.57, 95% CI 1.29 to 5.11). CONCLUSION: Maternal cardiac events can be predicted using CARPREG risk index. In Thai population, rheumatic heart disease was the most frequent form of cardiac problems in pregnant women.

Pure oxygen ventilation during general anaesthesia does not result in increased postoperative respiratory morbidity but decreases surgical site infection. An observational clinical study.

Background. Pure oxygen ventilation during anaesthesia is debatable, as it may lead to development of atelectasis. Rationale of the study was to demonstrate the harmlessness of ventilation with pure oxygen. Methods. This is a single-centre, one-department observational trial. Prospectively collected routine-data of 76,784 patients undergoing general, gynaecological, orthopaedic, and vascular surgery during 1995-2009 were retrospectively analysed. Postoperative hypoxia, unplanned ICU-admission, surgical site infection (SSI), postoperative nausea and vomiting (PONV), and hospital mortality were continuously recorded. During 1996 the anaesthetic ventilation for all patients was changed from 30% oxygen plus 70% nitrous oxide to 100% oxygen in low-flow mode. Therefore, in order to minimize the potential of confounding due to a variety of treatments being used, we directly compared years 1995 (30% oxygen) and 1997 (100%), whereas the period 1998 to 2009 is simply described. Results. Comparing 1995 to 1997 pure oxygen ventilation led to a decreased incidence of postoperative hypoxic events (4.3 to 3.0%; p < 0.0001) and hospital mortality (2.1 to 1.6%; p = 0.088) as well as SSI (8.0 to 5.0%; p < 0.0001) and PONV (21.6 to 17.5%; p < 0.0001). There was no effect on unplanned ICU-admission (1.1 to 0.9; p = 0.18). Conclusions. The observed effects may be partly due to pure oxygen ventilation, abandonment of nitrous oxide, and application of low-flow anesthesia. Pure oxygen ventilation during general anaesthesia is harmless, as long as certain standards are adhered to. It makes anaesthesia simpler and safer and may reduce clinical morbidity, such as postoperative hypoxia and surgical site infection.

Low-dose spinal morphine for post-thoracotomy pain: a prospective randomized study.

OBJECTIVE: To compare the results of 0.2 mg and 0.3 mg of spinal morphine in patients with post-thoracotomy pain. DESIGN: A prospective, randomized, double-blind study. SETTING: A university hospital and a tertiary referral center. PARTICIPANTS: Forty patients undergoing thoracotomy for lung resection. INTERVENTIONS: Spinal morphine: 0.2 mg or 0.3 mg. METHODS AND MAIN RESULTS: Patients were randomly allocated to receive either 0.2 mg or 0.3 mg of spinal morphine for post-thoracotomy pain prior to general anesthesia. Cumulative 24- and 48-hour intravenous patient-controlled analgesia meperidine consumption and numeric rating scale score for pain were recorded. The severity score (4-point scale) of sedation, nausea, vomiting, and pruritus was assessed for interval during the postoperative period. The times to first drinking/eating/sitting/walking were recorded. There was no statistically significant difference in 24-hour postoperative meperidine usages between the 2 groups, which were 110 (interquartile range 90-180) and 95 (interquartile range 57.5-175) mg, respectively. The median pain free times, time to first drinking, eating, sitting, and walking showed no differences between the 2 groups. The numeric rating scale score for pain and incidences of side effects were not different between the 2 groups. One patient who received 0.3 mg of spinal morphine developed respiratory acidosis with a respiratory rate of 10 per minute at 44 minutes after extubation. CONCLUSIONS: In patients who underwent elective thoracotomy, 0.2 mg of spinal morphine was as effective as 0.3 mg. Increasing the dosage of spinal morphine does not decrease postoperative meperidine consumption, but may lead to respiratory depression in rare cases.

Patients with osteoporotic hip fractures: factors affecting length of hospital stay (LOS) and outcome.

OBJECTIVE: Identify risk factors associated with prolonged hospital stay (LOS more than 14 days) in patients with osteoporotic hip fracture. MATERIAL AND METHOD: One hundred and fifty out of 356 patients with fractured femur were selected between April 2008 and August 2009. Analysis of patient's LOS (group I equal or less than 14 days, group II more than 14 days) is performed by backward binary multiple logistic regression. RESULTS: LOS in group I (n=46) was 12.5 (+/- 4) days compared to 21 (+/- 11) days in group II (n=104). Patients were mainly female (74%) and about 50% were aged over 80 years. The 30-days mortality in group I and II was zero and two patients respectively. Time-to-surgery was three days (+/- 2) in group I and seven (+/- 5) days in group II. Significant predicting risk factors were waiting for investigation (odds ratio (OR) 3.77, confidence interval (CI) 1.12-12.69) and receiving systemic opioids (OR 3.44; CI 1.54-7.66). CONCLUSION: Unnecessary surgery delay after hip fracture should be avoided. Higher need for opioids in those patients might be the result of prolonged waiting for surgical treatment.

Clinical characteristics of spinal levobupivacaine: hyperbaric compared with isobaric solution.

We performed a prospective, double-blinded study in 20 patients undergoing gynecologic surgery with lower abdominal incision, to investigate characteristics of intrathecal hyperbaric levobupivacaine compared with isobaric levobupivacaine. We randomly assigned them to receive 3 mL of either isobaric or hyperbaric 0.42% levobupivacaine intrathecally. We found that hyperbaric levobupivacaine, compared with isobaric levobupivacaine, spread faster to T10 level (2.8 ± 1.1 versus 6.6 ± 4.7 minutes, P = 0.039), reached higher sensory block levels at 5 and 15 minutes after injection (T8 versus L1, P = 0.011, and T4 versus T7, P = 0.027, resp.), and had a higher peak level (T4 versus T8, P = 0.040). Isobaric levobupivacaine caused a wider range of peak levels (L1 to C8) compared with hyperbaric form (T7 to T2). The level of T4 or higher reached 90% in the hyperbaric group compared with 20% in the isobaric group (P = 0.005). Our results suggest that hyperbaric levobupivacaine was more predictable for sensory block level and more effective for surgical procedures with lower abdominal approach. Hyperbaric levobupivacaine seems to be suitable, but the optimal dosage needs further investigation.

Comparison of age-based and height-based formula for tracheal tube size in cardiac children.

OBJECTIVE: To compare the effectiveness of age-based formula (ABF) and height-based formula (HBF) for pediatric cardiac patients, including patients with failure to thrive (FTT). MATERIAL AND METHOD: In a retrospective study of 260 cardiac patients that included those with failure to thrive, aged 2 to 7 years was done. The actual uncuffed endotracheal tube (ETT) size was compared with the predicted one, using both the ABF [ID (mm) = age (years)/4 + 4] and the HBF [ID (mm) = height (cm)/30 + 2]. RESULTS: ABF and HBF correctly predicted 50.8% and 50.4% of ETT sizes (p = 1.0), whereas three sizes of tubes (one above and one below the predicted size) cover 95.8% and 93.5% of the patients, respectively (p = 0.24). In patients with FTT, both the ABF and HBF correctly predicted 56.6% of ETT sizes. CONCLUSION: Age- and height-based formula for estimating tube size in cardio-surgical children is equivalent and independent of physical development. Age-based formula as the simple method can be recommended. The availability of three tube sizes (one smaller one larger than estimated) should be ensured.

Thoracic surgery mortality and morbidity in a university hospital.

This study was undertaken to determine the mortality and morbidity of lung resection surgery in the 2,415-bed Siriraj University Hospital, Thailand, and compare them to rates in similar facilities (benchmarking). Demographic and clinical data as well as perioperative outcome variables of patients who underwent elective thoracic surgery from January 2006 to May 2010 were reviewed retrospectively. There were 558 cases of lung resection. Mortality was 0.9% and perioperative morbidity was 8.2%. Univariate analysis identified age >75 years, history of pulmonary disease, preoperative rehabilitation consultation, and operative time >2 h as predictors of mortality and morbidity. With less statistical power, hypertension, cancer, peripheral vascular disease, and thoracotomy also contributed to perioperative outcome. Comparisons with data from the current literature place our results in the range of good quality. Following benchmarking criteria, perioperative outcomes after lung resection surgery in our hospital are good. To further improve quality, we will pay special attention to patients with advanced age and history of pulmonary disease.