1/13. Difficult anesthetic management during pheochromocytoma surgery.The anesthetic management of two middle-aged patients having surgical removal of large pheochromocytomas is described. The same team of physicians was involved in the care of the patients, including an endocrinologist, who supervised their preoperative care. Although the preoperative care included pharmacologic adrenergic receptor blockade and fluid administration, guidelines for surgical readiness did not follow those recommended in our literature. Both patients experienced severe intraoperative hypotension after complete interruption of the tumors' venous drainage, and one patient suffered a cardiac arrest. Explanations for the occurrence of these problems are discussed, including factors relating to the complexity of the disease process. However, it is conceivable that appropriate input from the anesthesiologist during the preoperative preparation of these patients may have ameliorated, if not prevented, the encountered difficulties.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/13. Perforation of the posterior tracheal wall during percutaneous dilatational tracheotomy.Dilatative percutaneous tracheotomy is more and more indicated in intensive-care medicine. We report on the perforation of the posterior tracheal wall observed in 3 patients after this procedure. In 2 patients the tracheo-oesophageal fistula was closed by the use of a pediculated flap from the infrahyoideal muscle. The third patient died due to the underlying disease. As demonstrated by the 3 cases reported here, this complication cannot be avoided in every case neither by the use of an endoscope nor by extensive personal experience of the physician. The possibility of this complication should be known, because it seems to be typical of this procedure. In the case of perforation of the posterior tracheal wall, active surgical treatment seems to be a successful method to deal with this complication.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
3/13. Perioperative risk. review of two guidelines for assessing older adults. American College of cardiology and american heart association.Elective in-patient surgery is a common occurrence among older persons and primary care physicians are routinely called on to provide preoperative assessment and perioperative risk management of these patients. Older patients undergoing noncardiac surgery may be at increased risk for cardiac or cardiovascular complications, thus perioperative assessment of risk in this population is prudent. Although the range of possible screens and diagnostic tools can make this task unwieldly, the clinical practice guidelines make it more manageable. Two guidelines in particular--one published jointly by the American College of cardiology and american heart association, the other by the American College of physicians--are particularly suited to perioperative assessment and risk management.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
4/13. Detection of clinically silent infarcts after carotid endarterectomy by use of diffusion-weighted imaging.BACKGROUND AND PURPOSE: Intraprocedural transcranial Doppler sonography has identified multiple microembolic events during and immediately after carotid endarterectomy (CEA) or angioplasty, yet the rate of clinically evident stroke is small. To determine the significance of the transcranial Doppler sonography findings, we examined patients by use of diffusion-weighted imaging and fluid-attenuated inversion recovery MR imaging before and immediately after CEA for evidence of clinically silent ischemic events. methods: Twenty-five patients with atherosclerotic disease of the carotid arteries underwent diffusion-weighted imaging and fluid-attenuated inversion recovery MR imaging performed, on average, 3 days before and 12 hours after CEA. diffusion-weighted images were acquired in three orthogonal directions at b = 900. Pre- and postoperative neurologic examinations were performed by the same physician. RESULTS: After endarterectomy, 4.0% of the patients (one of 25 patients) showed a single, cortical focus of restricted diffusion and new fluid-attenuated inversion recovery hyperintensity, measuring <1 cm in diameter, ipsilateral to the CEA. The postoperative neurologic examination showed no change in status from the preoperative baseline state. This patient had an intraoperative course complicated by the development of a large luminal thrombus, necessitating thrombectomy. CONCLUSION: The use of diffusion-weighted imaging may serve to improve conspicuity of clinically silent infarcts after CEA. An important next step is to determine the risk factors that predispose to detectable parenchymal ischemic events.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
5/13. beta-Blockers and reduction of cardiac events in noncardiac surgery: clinical applications.Recent studies suggest that beta-blockers administered perioperatively may reduce the risk of adverse cardiac events and mortality in patients who have cardiac risk factors and undergo major noncardiac surgery. The objective of this article is to provide practicing physicians with examples of perioperative beta-blocker use in practice by using several hypothetical cases. Although current evidence describing the effectiveness of perioperative beta-blockade may not address all possible clinical situations, it is possible to formulate an evidence-based approach that will maximize benefit to patients. We describe how information from several sources can be used to guide management of patients with limited exercise tolerance, those at highest risk for perioperative cardiac events, patients who are taking beta-blockers long-term, and those with relative contraindications to beta-blockade. Even though fine points of their use remain to be elucidated, perioperative beta-blocker use is important and can be easily applied in practice by any physician involved with the care of patients perioperatively.- - - - - - - - - - ranking = 2keywords = physician (Clic here for more details about this article) |
6/13. Repair of hypoplastic left heart syndrome of a 4.25-kg Jehovah's witness.The care of patients who refuse homologous transfusions has challenged cardiac surgery teams to refine blood conservation techniques and question standard transfusion practices. We cared for a newborn child with hypoplastic left heart syndrome (HLHS) whose parents refused to give consent to care for the child that involved the transfusion of homologous blood. A Norwood Stage I procedure was planned with the understanding that transfusions would be avoided, if possible. A court order was obtained that specified the conditions under which the attending physicians would transfuse the newborn. The birth weight of the patient was 4.25 kg. A low prime cardiopulmonary bypass (CPB) circuit and aggressive blood conservation techniques that included modified ultrafiltration (MUF) allowed the completion of the repair and CPB portion of the operation without the use of blood. The lowest hematocrit during CPB was 20%. After an unsuccessful attempt to separate from CPB, blood was transfused. Recovery was consistent for HLHS patients following Norwood Stage I. However, at 1 month postoperatively, the patient did require a shunt reduction for pulmonary overcirculation. Norwood Stage II repair was completed at age 4 months without donor blood. The key to a successful outcome is a well-thoughtout plan by the surgeon, anesthesiologist and perfusionist. This plan should include careful monitoring of the patient's oxygenation and cardiovascular status.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
7/13. cefotetan-induced hemolytic anemia after perioperative prophylaxis.Cephalosporin-induced hemolytic anemia is an acquired form of hemolytic anemia caused by interaction of drug with the immune system. Drug adsorption, drug-dependent antibody, and autoimmune induction are the three mechanisms of hemolysis. cefotetan-induced hemolytic anemia (CIHA) has been described to occur through all three mechanisms. We report four cases of CIHA that occurred after appropriate perioperative use of cefotetan. All of our patients developed an acute and severe hemolytic episode that caused significant symptoms and led to hospitalization within 1-2 weeks after exposure to cefotetan. The hemolytic process was self-limited, and all our patients responded to supportive measures and blood transfusion. This report adds to our knowledge of CIHA, a rare complication of cefotetan use. Our cases suggest that cefotetan-induced acute severe hemolysis is caused by membrane modification (nonimmunologic protein adsorption) in addition to immune complex formation. Prompt diagnosis and aggressive supportive measures are essential in minimizing morbidity and mortality from hemolysis. physicians should warn their patients about this complication. Given that hemolysis occurs when the subject is no longer under direct clinical supervision, patient awareness on how to recognize signs and symptoms of hemolysis is paramount to reducing the likelihood of this potentially lethal side effect. Finally, physicians might consider restricting cefotetan use.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
8/13. Unrecognized drug-drug interactions: a cause of intraoperative cardiac arrest?Many physicians overlook, or are unaware of, most drug-drug interactions. In our patient, the local anesthetic used for an axillary block may have been the precipitating drug in a cascade of drug-drug interactions that resulted in a cardiac arrest. The combination of multiple preoperative drug-drug interactions prevented the return of a stable native cardiac rhythm for almost 24 h. The mechanisms of interactions of these frequently used drugs are described, and the reader is guided to sources that identify and simplify the understanding of potentially dangerous drug-drug interactions.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
9/13. How to manage splenic rupture during major liver resection?Spontaneous splenic rupture is a rare but life threatening complication of major liver resection with only five reported cases during major liver resection under hepatic vascular occlusion. We report two cases of splenic rupture during liver resection including the first case during portal triad clamping. In both patients, the hemorrhage was stopped by removing the vascular clamp. A splenectomy was performed in both patients and liver resection was completed under vascular clamping without complications. Although very rare, physicians should be aware of the possibility of splenic rupture during liver resection because instead of increasing vascular occlusion, clamp removal usually stops the hemorrhage.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
10/13. Cricoarytenoid subluxation: complication of blind intubation with a lighted stylet.transillumination of the cervical airway with the light wand for blind intubation is a valuable adjunct to anesthesiologists and emergency room physicians, particularly for management of the complicated airway in which direct visualization of the larynx is not possible. However, as an alternative to traditional methods, this technique should be practiced in simple cases before it is attempted in more difficult airway cases. The technique is easy to learn but requires practice to master. The incidence of complications remains low but complications may be serious when they occur. We present a case of cricoarytenoid subluxation after blind intubation with a lighted stylet.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
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