Ultrasound and antral lavage in the examination of maxillary sinuses

Two hundred and ninety maxillary sinuses in 206 patients, suspected of having acute or prolonged maxillary sinusitis, were examined using ultrasound (US) and then irrigated with isotonic saline. The results of the antral lavage and the US were compared and various US recording variables were analyzed. The sensitivity of US examination to find maxillary sinus secretion was 77% and the specificity 49%. The distance from the initial echo to the back wall echo (BWE) and the ratio of the echo-free area to the distance from the initial echo to the BWE were sensitive indicators of the presence of maxillary sinus secretion. The results suggest that US is a relatively sensitive method also in the diagnosis of prolonged maxillary sinus inflammations. However, its low specificity weakens its value in clinical work. The usability of US in the diagnosis of maxillary sinusitis can be increased by intermittently controlling US findings by sinus puncture. This is of particular importance for general practitioners, but also for specialists.

[Perioperative administration of bicarbonated solution to a patient with mitochondrial encephalomyopathy]

A 16-year-old man with mitochondrial encephalomyopathy underwent biopsy and nephrectomy under general anesthesia. Mitochondrial encephalomyopathy is caused by mitochondrial dysfunction, and frequently accompanies elevation of lactic and pyruvic acid levels in the blood. It has been considered that problems of anesthesia for the patient with mitochondrial encephalomyopathy are the probability of hyperlactacidemia, the relevance to malignant hyperthermia, the possibility of myocardial disease and dysfunction of heart conduction system, respiratory depression due to muscle weakness, and so on. Therefore, to prevent hyperlactacidemia, we prepared the extracellular fluid solution including bicarbonic acid but no lactic and acetic acid, and infused the solution to the patient during anesthesia. By use of this solution, his lactic acid level was kept within the normal range during anesthesia and no metabolic acidosis occurred. His hemodynamics was stable and he showed normal response to vecuronium, recovering from anesthesia smoothly and postoperative course was uneventful.

IL-7 administration alters the CD4:CD8 ratio, increases T cell numbers, and increases T cell function in the absence of activation

IL-7 is vital for the development of the immune system and profoundly enhances the function of mature T cells. Chronic administration of IL-7 to mice markedly increases T cell numbers, especially CD8(+) T cells, and enhances T cell functional potential. However, the mechanism by which these effects occur remains unclear. This report demonstrates that only 2 days of IL-7 treatment is needed for maximal enhancement of T cell function, as measured by proliferation, with a 6- to 12-fold increase in the proportion of CD4(+) and CD8(+) T cells in cell cycle by 18 h of ex vivo stimulation. Moreover, a 2-day administration of IL-7 in vivo increases basal proliferation by 4- and 14-fold in CD4(+) and CD8(+) T cells, respectively. These effects occur in the absence of cytokine production, increases in most activation markers, and changes in memory markers. This enhanced basal proliferation is the basis for the increase in T cell numbers in that IL-7 induces an additional 60% and 85% of resting CD4(+) and CD8(+) T cells, respectively, to enter cell cycle in mice given IL-7 for 7 days. These results demonstrate that in vivo administration of IL-7 increases T cell numbers and functional potential via a homeostatic, nonactivating process. These findings may suggest a unique clinical niche for IL-7 in that IL-7 therapy may increase T cell numbers and enhance responses to specific antigenic targets while avoiding a general, nonspecific activation of the T cell population.

[Endoscopic bronchial care in patients with chronic bronchitis]

Endoscopic bronchial sanitation was made in 194 patients with an exacerbation of chronic bronchitis. Catarrhal and purulent endobronchitis was endoscopically diagnosed in 121 and 73 patients, respectively. For endoscopic sanitation, therapeutical lavage was used at fiber bronchoscopy. Ringer's solution added by methyluracil and dioxidine was used as a wash liquid. In patients with staphylococcal or streptococcal infection, the bronchial washing was completed by the administration of specific phage preparations. Good and fair effects could be achieved in 97.7 of the treated patients.

Neuroendocrine effects of a short-term osmotic stimulus in patients with chronic schizophrenia

We studied the effects of a short-term hypertonic stimulus on plasma levels of the stress hormones adrenocorticotropin (ACTH), cortisol, prolactin, and the blood volume- and electrolyte-controlling hormones arginine vasopressin (AVP) and atrial natriuretic peptide (ANP). Seven patients suffering from chronic schizophrenia with negative symptoms and ten healthy control subjects were investigated by a 20-minute infusion of 10 ml/kg body weight of hypertonic (2.5%) versus isotonic (0.9%) saline. All patients, who were medication-free for at least one week prior to the study, and all control subjects participated in two investigations in randomized order according to a single-blind cross-over design. During hypertonic infusion, plasma osmolarity and sodium levels were increased similarly in both groups and significantly more than during isotonic saline. Hypertonic saline caused a significant increase of plasma ACTH, cortisol and prolactin in patients in contrast to controls. AVP and ANP plasma concentrations were elevated after infusion of hypertonic saline, however, only patients showed a significant rise in plasma ANP. These results show that a dysregulation of the hypothalamic-pituitary-adrenal (HPA) system in a subset of patients with chronic schizophrenia may become overt during an osmotic stimulation, indicating an increased sensitivity of patients with schizophrenia to osmotic stress.

Systemic Exophiala jeanselmei infection in a cat

A 14-year-old spayed domestic shorthair cat was referred for ultrasonographic evaluation of abnormally shaped kidneys. Multifocal lesions were detected ultrasonographically in the liver and kidneys; a fine-needle aspirate of the kidneys was performed, and numerous clumps of fungal hyphae were identified. The following day, the cat was recumbent with advanced neurologic signs. The cat was euthanatized, and a necropsy was performed. Multifocal granuloma-like masses were seen on the liver, kidneys, abdominal wall, mesentery, thoracic wall, pericardium, and epicardium. Similar lesions were found on the cervical portion of the spinal cord, the cerebrum, and cerebellum. Exophiala jeanselmei, an organism of the phaeohyphomycotic group, was identified on fungal culture. To our knowledge, systemic infections caused by this organism have not been reported. However, phaeohyphomycotic infections are believed to be an emerging disease in humans.

Effects of a novel antioxidant during resuscitation from severe blunt chest trauma

Previous work suggests that neutrophils (PMNs) and/or prostaglandins might mediate the progressive respiratory failure after severe pulmonary contusion. Since reactive oxygen metabolites are closely associated with both these factors, we examined the actions of a novel antioxidant after swine received a unilateral injury followed by 25% hemorrhage. An infusion (2mL/kg/h intravenously x 6 h) of either polynitroxylated 5% Dextran + Tempol (PND, n = 9), 5% Dextran (D, n = 6), or lactated Ringers (LR, n = 13) was begun 60 min post-injury to mimic 'pre-hospital resuscitation.' After 15 min, standard resuscitation was initiated (3x shed blood as LR in 30 min) plus further LR for 6 h to maintain hemodynamics. The total LR requirement was lower with PND (1,772+/-267 mL) versus D (3,040+/-689, P = 0.0563) or LR (4145+/-398, P = 0.0005). The ipsilateral bronchoalveolar lavage (BAL) PMN count with PND (8+/-2 x 10(5)/mL), was not different from its baseline (P = 0.131), but the counts with D (16+/-3) and LR (17+/-4) were both higher than their baselines (P = 0.0184 and 0.0431). Similarly, BAL protein with PND (1,560+/-350 mg %) was not elevated from its baseline (P = 0.0721), but the values with D (2,560+/-498) and LR (2,474+/-899) were both higher than their baselines (P = 0.0169 and 0.0325). In the contralateral (uninjured) lung, the effects were similar, but the increases were less for PMNs (8+/-2 versus 10+/-2 or 14+/-4 x 10(5)/mL) and for protein (609 +/-153 versus 1,955+/-671 or 1486+/-357 mg %). Despite these significant BAL changes, there was no obvious improvement in cardiopulmonary dysfunction. Thus oxidants probably have some role in the pathogenic mechanism of progressive secondary injury after thoracic trauma, but further work is needed to determine the therapeutic potential of antioxidants because no clinical improvement was detected.

Rapid induction of mild cerebral hypothermia by cold aortic flush achieves normal recovery in a dog outcome model with 20-minute exsanguination cardiac arrest

OBJECTIVES

Resuscitation attempts in trauma victims who suffer cardiac arrest (CA) from exsanguination almost always fail. The authors hypothesized that an aortic arch flush with cold normal saline solution (NSS) at the start of exsanguination CA can preserve cerebral viability during 20-minute no-flow.

METHODS

Twelve dogs were exsanguinated over 5 minutes to CA of 20-minute no-flow, resuscitated by cardiopulmonary bypass, followed by post-CA mild hypothermia (34 degrees C) continued to 12 hours, controlled ventilation to 20 hours, and intensive care to 72 hours. At CA 2 minutes, the dogs received a 500-mL flush of NSS at either 24 degrees C (group 1, n = 6) or 4 degrees C (group 2, n = 6), using a balloon-tipped catheter inserted via the femoral artery into the descending thoracic aorta.

RESULTS

The flush at 24 degrees C (group 1) decreased tympanic membrane temperature [mean (+/-SD)] from 37.5 degrees C (+/-0.1) to 35.7 degrees C (+/-0.2); the flush at 4 degrees C (group 2) to 34.0 degrees C (+/-1.1) (p = 0.005). In group 1, one dog achieved overall performance category (OPC) 2 (moderate disability), one OPC 3 (severe disability), and four OPC 4 (coma). In group 2, four dogs achieved OPC 1 (normal), one OPC 2, and one OPC 3 (p = 0.008). Neurologic deficit scores (0-10% normal, 100% brain death) [median (25th-75th percentile)] were 62% (40-66) in group 1 and 5% (0-19) in group 2 (p = 0.01). Total brain histologic damage scores were 130 (62-137) in group 1 and 24 (10-55) in group 2 (p = 0.008).

CONCLUSIONS

Aortic arch flush of 4 degrees C at the start of CA of 20 minutes rapidly induces mild cerebral hypothermia and can lead to normal functional recovery with minimal histologic brain damage. The same model with aortic arch flush of 24 degrees C results in survival with brain damage in all dogs, which makes it suitable for testing other (e.g., pharmacologic) preservation potentials.

[Multiple organ failure in experimental pancreatitis]

BACKGROUND

Multiple organ failure (MOF) is the most severe complication and the most frequent cause of death in acute necrotizing pancreatitis (ANP).

OBJECTIVE

To evaluate the components and the time course of MOF in an experimental model of ANP.

METHOD

Induction of ANP in rats by a standardised bile-salt infusion into the pancreatic duct and i.v. cerulein hyperstimulation. Six hours after AP-induction animals were randomised into 4 groups to receive (I) no therapy; (II.) 4 ml/kg/h Ringer lactate (R.L) i.v.; (III) 8 ml/kg/h RL i.v.; or (IV) 4 ml/kg/h RL plus an endothelin receptor antagonist. Animals were observed for 24 hours and vital parameters were investigated.

RESULTS

After 6 hrs all animals presented with severe haemoconcentration (hematokcrit > 57%) and oliguria (< 0.5 ml/6 hrs). Until 12 hrs following AP-induction in animals without therapy increased hematocrit and oliguria was observed. Animals receiving fluid resuscitation had a significant drop in hematocrit and kept their blood gas values compensated. Between 12 and 24 hrs urine production significantly increased with fluid resuscitation and respiratory parameters stabilised except for animals treated with 8 ml/kg/h RL. These animals developed arterial hypoxia and hypercapnia.

CONCLUSIONS

(1) In the early phase of ANP in our model renal failure developed. (2) Massive fluid resuscitation that is necessary to increase urine output may lead to respiratory distress. (3) Reduction of intravascular fluid loss by endothelin receptor blockade is associated with improved renal and respiratory function.

Nutritional support for treatment of hepatic lipidosis in a llama

A 3-year-old female llama that was 3 months into her first lactation and 10 weeks pregnant was evaluated for anorexia of 24 hours' duration. On physical examination, the llama was in lateral recumbency, bradycardic, tachypneic, and hyperthermic. Palpation per rectum confirmed the presence of a possible dry fecal mass in the spiral colon. A tissue biopsy specimen of the liver was obtained, and histologic examination revealed moderate diffuse lipid accumulation within the hepatocytes. Lactated Ringer's solution was administered for rehydration, and partial parenteral nutrition was then initiated. Hepatic lipidosis is a disease characterized by abnormal accumulation of lipid in the liver and is associated with high mortality in camelids. Anorexia associated with hepatic lipidosis promotes further lipid mobilization and fatty infiltration of the liver. Partial parenteral nutrition with enteral supplementation may be used to maintain adequate energy intake and minimize further lipid mobilization. The distinctive metabolism of camelids may require higher amino acid supplementation relative to nonprotein calories in parenteral solutions than those traditionally provided to other species. Treatment with insulin may be effective

Evaluation and treatment of thermal injuries

An estimated 1 to 2 million Americans suffer burn injuries each year. The majority of these are minor; however, approximately 70,000 individuals sustain injuries severe enough to require admission to a hospital or burn center for treatment.

[The effect of acetate ringer solution, 6% hydroxyethyl starch saline and 20% mannitol solution on the serum concentration of propofol continuously infused]

Changes in serum concentrations of propofol after administration of three different fluids were investigated in 42 scheduled surgical patients. Anesthesia was induced with propofol 2 mg.kg-1 and maintained with constant rate infusion of propofol 6 mg.kg-1.hr-1. After achieving a stable depth of anesthesia, 5 ml.kg-1 of acetate Ringer's solution, 6% hydroxyethyl starch saline solution or 20% mannitol solution was infused in 15 minutes. Blood samples each 2 ml were taken before and 0, 5, 15, 30 and 60 minutes after fluid treatment. We measured hemoglobin and hematocrit of the samples for calculating the dilution rate of the plasma with infusion treatment, and determined the serum concentration of propofol by HPLC-spectrofluorometry. After administration of each fluid, the serum concentrations of propofol decreased significantly to 17 +/- 15, 25 +/- 10 and 35 +/- 8%, respectively (mean +/- SEM). The dilution rate of the plasma from the fractional change in blood hemoglobin increased to 0.08 +/- 0.02, 0.24 +/- 0.03, and 0.36 +/- 0.03, respectively. Administration of mannitol might markedly increase distribution volume of propofol, and this can be attributed to osmotic action of mannitol and resultant expansion of extracellular fluid volume. The results of the present investigation suggest that this pharmacokinetic change decreased the concentration of propofol more significantly in mannitol treatment patients than in Ringer's solution or 6% hydroxyethyl starch saline treatment patients.

A pilot study of protein sparing in healthy dogs using peripheral parenteral nutrition

Total parenteral nutrition is the standard nutritional support of dogs when the enteral route is contraindicated, but it can be difficult because of cost, technical difficulties, and potential complications. Peripheral parenteral nutrition (PPN) may be a feasible option for short-term support in some cases. The objectives of this study were to determine the effect of PPN on nitrogen balance (as an indicator of the effect on protein sparing), serum folate concentrations and serum insulin-like growth factor-I (IGF - I) concentrations in fasting dogs. The effect of PPN on these parameters has not previously been reported in dogs. Using a cross-over design, three healthy adult fasting dogs were randomly assigned to three treatments: 5 per cent amino acid solution, 5 per cent glucose solution, and a control electrolyte solution. The solutions were administered into a peripheral vein at 60 ml kg(-1)per day for 4 days. The amino acid infusion resulted in a positive nitrogen balance and the glucose infusion produced less nitrogen loss than the control. Amino acid, but not glucose or electrolyte infusions, decreased serum folate concentrations. Amino acid and glucose infusions resulted in higher serum IGF -I concentrations than electrolyte infusions, although the differences were small and IGF -I decreased in all cases. In conclusion, these findings suggest that PPN increases nitrogen balance in healthy dogs undergoing short-term fasting.

The use of insulin and glucose during resuscitation from hemorrhagic shock increases hepatic ATP

BACKGROUND

Hemorrhagic shock produces a marked decrease in hepatic ATP, adenylate energy charge, and total adenosine nucleotides. This is followed by slow recovery to normal levels after resuscitation. Nucleotide metabolites are increased following shock and resuscitation. Previous experimental work has shown that supraphysiologic doses of insulin have salutary effects in animals with hemorrhagic shock and in cardiac patients. It appears that insulin causes increased availability of glucose and energy-producing substrates. This study examined whether resuscitation with glucose and insulin after hemorrhagic shock would alter the changes previously seen to occur in hepatic ATP levels, adenylate energy charge, or nucleotide metabolites.

METHODS

Male Sprague-Dawley rats were bled to a mean arterial blood pressure of 40 mm Hg for 30 min. They were then resuscitated with the shed blood and one of three fluids: (1) lactated Ringer's, (2) lactated Ringer's with 10% glucose, (3) lactated Ringer's with 10% glucose + 6 units/kg regular insulin. Liver biopsies were obtained prior to shock (baseline), after 30 min of shock (shock), and 90 min after resuscitation (90 min). Tissue levels of ATP, ADP, AMP, adenosine, inosine, hypoxanthine, and xanthine were measured. Serum at 90 min was evaluated for potassium, glucose, and tumor necrosis factor alpha (TNF-alpha).

RESULTS

The insulin-treated group had significantly increased hepatic ATP and energy charge following resuscitation compared with the other two groups. The insulin group also exhibited significant hypoglycemia. Total adenine nucleotides (ATP, ADP, and AMP) were significantly elevated 90 min postresuscitation in the insulin group. Mean blood pressures throughout the experiment were not significantly different among groups. TNF-alpha was highest in the insulin-treated group, but this was not significant.

CONCLUSIONS

Resuscitation with insulin and dextrose significantly increased hepatic ATP and adenylate energy charge after hemorrhagic shock in rats. Total nucleotide pool levels were not different between groups, indicating that there was a shift of the equilibrium away from the metabolites toward ATP and ADP in the insulin-treated group. Insulin treatment had no significant effect on blood pressure or TNF-alpha. However, it caused significant hypoglycemia and hypokalemia.

Detrimental effects of acute heparin administration on ischemic threshold in patients with coronary artery disease

BACKGROUND

Recent studies have indicated that heparin administration might decrease endothelial nitric oxide production. The aim of this study was to investigate the effect of heparin on ischemic threshold.

METHODS

Eighteen patients with a positive exercise test and proven coronary artery disease were submitted to a randomized, placebo-controlled trial using i.v. 0.9% NaCl as placebo and i.v. heparin (5,000 IU bolus + 1,000 IU/h). After both saline and heparin bolus, the infusion was started and, after 10 min, the exercise test was performed. Blood samples for nitric oxide metabolites and free fatty acid determinations were taken before, at peak exercise, and at ECG recovery.

RESULTS

As compared to placebo, heparin significantly decreased time to 1 mm ST segment depression (241 +/- 160 vs 303 +/- 175 s, p = 0.003) and prolonged recovery (573 +/- 177 vs 441 +/- 195 s, p = 0.003), while exercise duration was similar. Accordingly, rate-pressure product at 1 mm ST segment depression was lower after heparin, while it was similar at peak exercise. No significant differences were found for plasma nitric oxide metabolite levels. Conversely, free fatty acid levels were higher after heparin throughout the study in all patients. The increase in free fatty acids was not correlated with the difference in rate-pressure product at 1 mm ST segment depression between placebo and heparin (r = 0.34, p = NS).

CONCLUSIONS

In patients with stable coronary artery disease, heparin significantly decreased exercise ischemic threshold. The lower rate-pressure product at 1 mm ST segment depression during heparin, compared to placebo, suggests an impairment of coronary blood flow, which does not seem to be mediated by decreased nitric oxide production/release. The increased free fatty acid release, on the other hand, might contribute to the detrimental effect of heparin on exercise-induced ischemia, but the lack of a correlation with changes in ischemic threshold suggests that other, still unknown, factors are involved.

[Anesthetic management of a patient with mitochondrial encephalomyopathy]

A 46-year-old female with mitochondrial encephalomyopathy underwent the replacement of right femur head under continuous epidural anesthesia. Considering that this disease is a neuromuscular disorder, general anesthesia should be avoided. In addition, the patients with mitochondrial encephalomyopathy tend to show increased concentrations of lactate and pyruvate caused by perioperative stress. Use of lactated Ringer's solution may elevate these concentrations. We managed this patient uneventfully with continuous epidural anesthesia and the use of acetated Ringer's solution during the perioperative period. We consider that continuous epidural anesthesia is useful for a patient with mitochondrial encephalomyopathy.

Does preservative-free lignocaine 1% for hydrodissection reduce pain during phacoemulsification?

PURPOSE

To compare preservative-free 1% lignocaine with balanced salt solution (BSS) in alleviating pain during hydrodissection in phacoemulsification cataract surgery.

SETTING

West Norwich Hospital, Norfolk, United Kingdom.

METHODS

This prospective double-masked trial comprised 68 patients having day-case phacoemulsification cataract surgery. Patients were randomly divided into 2 groups, receiving either BSS or lignocaine 1% solution for hydrodissection during routine uneventful phacoemulsification using topical anesthesia. The level of intraoperative pain was scored on a scale of 0 (no pain) to 10 (severe pain), and the scores between the 2 groups were compared.

RESULTS

Of the 68 patients, 33 (49%) received BSS and 35 (51%), lignocaine 1% solution. A pain score greater than 2 was considered clinically significant; 28 patients (85%) in the BSS group and 25 (71%) in the lignocaine 1% group scored 2 or less. The chi-square and Mann-Whitney tests found no significant difference between the BSS and lignocaine 1% groups (P = .30 and P = .432, respectively).

CONCLUSION

There was no significant difference in the pain scores in patients who received BSS or lignocaine 1% solution. Thus, we conclude that hydrodissecting with lignocaine 1% solution does not provide added pain relief during phacoemulsification.

[Utility of Ringer's acetate solution as an intraoperative fluid during cardiovascular surgery with cardiopulmonary bypass]

This study aimed to clarify the difference in the effects of Ringer's acetate (AR) and Ringer's lactate (LR) administration during cardiovascular surgery with cardiopulmonary bypass. We evaluated their effects on intra and postoperative metabolism, liver functions, blood gas and hemodynamic states. Twenty patients were divided into two groups; AR group (n = 10) and LR group (n = 10). Intraoperative serum D-lactate levels in LR group were significantly higher than those in AR group from the beginning of the operation to awakening. Serum acetate levels showed no increase in both groups. The arterial ketone body ratio (AKBR) in AR group was higher than that in LR group, but the difference was not significant. Serum glutamic pyruvic transaminase (GPT) and alkaline phosphatase (ALP) levels in LR group were significantly higher than those in AR group from the induction of the anesthesia. It has been reported that acetate has a greater vasodialatory effect than lactate. However, our findings indicate no significant difference in hemodynamics between the two groups. These results suggest that AR may be more useful than LR during cardiovascular surgery with cardiopulmonary bypass.

Evaluation of a method for noninvasive intracranial pressure assessment during infusion studies in patients with hydrocephalus

OBJECT

A mathematical model previously introduced by the authors allowed noninvasive intracranial pressure (nICP) assessment. In the present study the authors investigated this model as an aid in predicting the time course of raised ICP during infusion tests in patients with hydrocephalus and its suitability for estimating the resistance to outflow of cerebrospinal fluid (Rcsf).

METHODS

Twenty-one patients with hydrocephalus were studied. The nICP was calculated from the arterial blood pressure (ABP) waveform by using a linear signal transformation, which was dynamically modified by the relationship between ABP and cerebral blood flow velocity. This model was verified by comparison of nICP with "real" ICP measured during lumbar infusion tests. In all simulations, parallel increases in real ICP and nICP were evident. The simulated Rcsf was computed using nICP and then compared with Rcsf computed from real ICP. The mean absolute error between real and simulated Rcsf was 4.1 +/- 2.2 mm Hg minute/ml. By the construction of simulations specific to different subtypes of hydrocephalus arising from various causes, the mean error decreased to 2.7 +/- 1.7 mm Hg minute/ml, whereas the correlation between real and simulated Rcsf increased from R = 0.73 to R = 0.89 (p < 0.001).

CONCLUSIONS

The validity of the mathematical model was confirmed in this study. The creation of type-specific simulations resulted in substantial improvements in the accuracy of ICP assessment. Improvement strategies could be important because of a potential clinical benefit from this method.

[Two cases of extreme hemodilution caused by massive hemorrhage immediately after start of operation]

We describe two cases of extreme hemodilution due to large amounts of fluid infusion for unexpected massive hemorrhage. In both cases, unexpected hemorrhage with difficult hemostasis occurred within 60 min after the start of the operation. For lack of transfused blood, large amounts of fluid infusion using crystalloid and colloid solutions including 5% albumin, plasma expander and lactated Ringer's solution were administered to maintain circulatory blood volume. The hemoglobin concentration and hematocrit had been below 2.0 g.dl-1 and 10% for approximately one hour, respectively. The extreme hemodilution improved by the urgent blood transfusion. In one case, intraoperative autotransfusion with Cell-Saver was performed. In spite of intraoperative extreme hemodilution, their postoperative courses were uneventful. Intraoperative awareness was present in both cases.

Amnioinfusion for meconium-stained liquor

Amnioinfusion reduces the risk of meconium aspiration by the infants of women with thick meconium staining of the amniotic fluid. The benefits are clear in facilities with high baseline rates of meconium aspiration, and are therefore likely to outweigh the risk of uncommon but serious maternal side-effects. Larger randomized trials are needed to determine more precisely the relative risks and benefits in facilities with low baseline rates of meconium aspiration. The addition of antibiotics to the infusate has not been shown to reduce the risk of sepsis related to meconium.