Labetalol: response and safety in critically ill hemorrhagic stroke patients

OBJECTIVE

To observe and characterize the blood pressure (BP)-lowering and adverse hemodynamic and/or central nervous system effects of intravenous bolus doses of labetalol in hemorrhagic stroke patients.

DESIGN

Observational, prospective, pilot survey conducted over an eight-week period.

SETTING

Surgical intensive care unit.

PARTICIPANTS

Patients admitted with an intracerebral or subarachnoid hemorrhage.

MAIN OUTCOME PARAMETERS

Absolute decline in systolic BP (SBP) and diastolic BP (DBP), time to peak reduction in SBP and DBP, and adverse hemodynamic and mental status changes.

RESULTS

Labetalol at doses between 5 and 25 mg lowered SBP by 6-19 percent (baseline 152-184 mm Hg) and DBP by 3-26 percent (baseline 50-99 mm Hg). Adverse hemodynamic or mental status changes were not detected following labetalol administration.

CONCLUSIONS

Small (< or = 25 mg) intravenous bolus doses of labetalol produce mild decreases in BP in hemorrhagic stroke patients.

Effects of epidural anesthesia and analgesia on coagulation and outcome after major vascular surgery

To examine the interaction of epidural anesthesia, coagulation status, and outcome after lower extremity revascularization, 80 patients with atherosclerotic vascular disease were prospectively randomized to receive general anesthesia combined with postoperative epidural analgesia (GEN-EPI) or general anesthesia with on-demand narcotic analgesia (GEN). Demographics did not differ between groups except that the GEN-EPI group had a higher incidence of diabetes mellitus and of previous myocardial infarction. Coagulation status was monitored using thromboelastography. An additional 40 randomly selected patients without atherosclerotic vascular disease undergoing noncardiovascular procedures served as controls for coagulation status. Vascular surgical patients were hypercoagulable compared with control patients before operation and on the first postoperative day. Postoperatively, this hypercoagulability was attenuated in the GEN-EPI group and was associated with a lower incidence of thrombotic events (peripheral arterial graft coronary artery or deep vein thromboses). The rates of cardiovascular, infectious, and overall postoperative complications, as well as duration of intensive care unit stay, were significantly reduced in the GEN-EPI group. Stepwise logistic regression demonstrated that the only significant predictors of postoperative cardiovascular complications were preoperative congestive heart failure and general anesthesia without epidural analgesia. We conclude that in patients with atherosclerotic vascular disease undergoing arterial reconstructive surgery (a) thromboelastographic evidence of increased platelet-fibrinogen interaction is associated with early postoperative thrombotic events, and (b) epidural anesthesia and analgesia is associated with beneficial effects on coagulation status and postoperative outcome compared with intermittent on-demand opioid analgesia.

Melanotic neuroectodermal tumour of infancy (progonoma)

A case of Melanotic neuroectodermal tumour of infancy (melanotic progonoma, melanoameloblastoma, retinal anlarge tumour) presenting as tumour of maxilla in a female infant is reported. Clinically a teratoma was suspected but ultrasound shoved it a solid mass. At exploration, characteristic melanotic pigmentation clinched the diagnosis which was later confirmed by histopathological examination.

Transanal and intraperitoneal prolapse in intussusception

An infant with intussusception who developed an unusual complication of transanal and intraperitoneal prolapse is reported. Complete venous occlusion of the intussusceptum for a prolonged period in a patient with congenital anomalous vascular supply of the colon is suggested as a mechanism responsible for rupture of the intussuscepiens.

Infantile myofibromatosis of omentum

A unique case of solitary infantile myofibromatosis arising in the omentum is presented. The essentiality of wide surgical resection to avoid recurrence is emphasised.

Successful management of late presentation neonatal oesophageal atresia with distal tracheo-oesophageal fistula and significant pulmonary complications

The successful management of a neonate presenting with oesophageal atresia and a distal tracheo-oesophageal fistula on the twelfth day of life is described. This case is the most delayed diagnosis associated with survival known to have been reported. There were significant pulmonary complications at presentation and initial treatment was by gastrostomy under local anaesthesia, followed by a delayed primary repair.

Chronic perianal fistula: beware of rectal duplication

A child with cystic duplication of the rectum containing ectopic duodenal mucosa and aberrant pancreatic tissue presenting as a chronic perianal fistula is reported. The duplication was removed by subtotal excision of the cyst along with mucosal sleeve resection from the common septum with the rectal wall.