Correction of intraoperative coagulopathy in a patient with neurofibromatosis type I with intravenous desmopressin (DDAVP)

A patient with the genetic condition neurofibromatosis type I and no known coagulopathy undergoing cesarean delivery, had diffuse uterine and surgical site bleeding that was not correctable by oxytocin, methylergonovine and PGF2 alpha. Despite good uterine tone, hemorrhage continued from the uterus and the surrounding tissues, persisting even after surgical ligation of the uterine arteries. With no change in her condition, which was behaving clinically as a coagulopathy, an infusion of desmopressin acetate (DDAVP) was begun. The patient's bleeding promptly resolved shortly after infusion of this agent. A review of relevant literature suggests that platelet reactivity of patients with neurofibromatosis type 1 is attenuated in some in vitro conditions. Thus, there may be some theoretical basis for using DDAVP in patients with neurofibromatosis type 1 who have bleeding problems with no other known source, such as in the case presented here.

Effects of insulin-sensitising agents in mice with hepatic insulin resistance

AIMS/HYPOTHESIS

The metabolic abnormalities of insulin resistance are ameliorated by insulin sensitisers via different mechanisms. Metformin decreases hepatic glucose output, whereas rosiglitazone (RSG) is an agonist for peroxisome proliferator activated receptor (PPAR)gamma, highly expressed in fat. To gain insight into the mechanisms of action of these drugs, we compared their actions in two models of insulin resistance: the obese, hyperglycaemic ob/ob mouse and the liver specific insulin receptor knockout (LIRKO) mouse.

METHODS

Control, ob/ob, and LIRKO mice were divided into three groups that received metformin (300 mg/kg body weight/day), RSG (3 mg/kg body weight/day), or placebo for 3 weeks.

RESULTS

In the presence of the severe hepatic insulin resistance of the LIRKO mouse, neither metformin nor RSG had any significant effect on glucose or insulin tolerance tests. On the other hand, RSG decreased serum concentrations of total cholesterol, LDL, and HDL in LIRKO mice. Adipocyte PPARgamma gene and protein expression, and adipocyte size were all increased in LIRKO mice treated with RSG, whereas fat-cell size in control animals was decreased by RSG.

CONCLUSION/INTERPRETATION

TZDs probably improve some lipid parameters of the dysmetabolic syndrome associated with diabetes mellitus even in the presence of absolute hepatic insulin resistance, but both metformin and TZDs require an operating insulin signalling system in the liver for their effects in glucose homeostasis.

Phenylephrine added to prophylactic ephedrine infusion during spinal anesthesia for elective cesarean section

BACKGROUND

Because ephedrine infusion (2 mg/min) does not adequately prevent spinal hypotension during cesarean delivery, the authors investigated whether adding phenylephrine would improve its efficacy.

METHODS

Thirty-nine parturients with American Society of Anesthesiologists physical status I-II who were scheduled for cesarean delivery received a crystalloid preload of 15 ml/kg. Spinal anesthesia was performed using 11 mg hyperbaric bupivacaine, 2.5 microg sufentanil, and 0.1 mg morphine. Maternal heart rate and systolic blood pressure were measured at frequent intervals. A vasopressor infusion was started immediately after spinal injection of either 2 mg/min ephedrine plus 10 microg/min phenylephrine or 2 mg/min ephedrine alone. Treatments were assigned randomly in a double-blind fashion. The infusion rate was adjusted according to systolic blood pressure using a predefined algorithm. Hypotension, defined as systolic blood pressure less than 100 mmHg and less than 80% of baseline, was treated with 6 mg ephedrine bolus doses.

RESULTS

Hypotension occurred less frequently in the ephedrine-phenylephrine group than in the ephedrine-alone group: 37% versus 75% (P = 0.02). Ephedrine (36+/-16 mg, mean +/- SD) plus 178+/-81 microg phenylephrine was infused in former group, whereas 54+/-18 mg ephedrine was infused in the latter. Median supplemental ephedrine requirements and nausea scores (0-3) were less in the ephedrine-phenylephrine group (0 vs. 12 mg, P = 0.02; and 0 vs. 1.5, P = 0.01, respectively). Umbilical artery pH values were significantly higher in the ephedrine-phenylephrine group than in the group that received ephedrine alone (7.24 vs. 7.19). Apgar scores were similarly good in both groups.

CONCLUSION

Phenylephrine added to an infusion of ephedrine halved the incidence of hypotension and increased umbilical cord pH.

Walking with labor epidural analgesia: the impact of bupivacaine concentration and a lidocaine-epinephrine test dose

BACKGROUND

Regional analgesia techniques for labor that permit ambulation are popular among parturients. This study evaluated the influence of bupivacaine bolus concentration and a 3-ml 1.5% lidocaine-epinephrine test dose, on analgesic effectiveness and the ability to walk after block placement.

METHODS

Using a randomized double-blind study design, epidural analgesia was initiated in 60 parturients undergoing labor as follows: Group TD/B.0625 received a 3-ml lidocaine-epinephrine test dose + 12 ml bupivacaine, 0.0625%; group TD/B.125 received a 3-ml test dose + 12 ml bupivacaine, 0.125%; group B.0625 received 15 ml bupivacaine, 0.0625% (no test dose); and group B.125 received 15 ml bupivacaine, 0.125% (no test dose). Initial boluses in all groups contained 10 microg sufentanil. Bupivacaine, 0.0625%, with 0.33 microg/ml sufentanil was infused throughout labor at 13.5-15 ml/h. Analgesia balance, proprioception, motor block, and patient ability to stand and walk were evaluated at various intervals.

RESULTS

A bolus of 0.125% bupivacaine containing sufentanil, without a previous test dose, proved to be optimal with respect to analgesia and early ambulation. When a test dose was given before bupivacaine, 0.125%, fewer women walked within 1 h of block placement. Bupivacaine, 0.0625%, with sufentanil, with or without a test dose, provided inadequate analgesia, necessitating additional bupivacaine, which impaired the ability to walk. A high percentage of women in all groups (73-93%) walked at some stage during labor.

CONCLUSIONS

Omitting a lidocaine-epinephrine test dose and using 0.125% bupivacaine for the initial bolus should permit ambulation in the early postblock period for most parturients who elect this option.

Progression of microalbuminuria to proteinuria in type 1 diabetes: nonlinear relationship with hyperglycemia

While small clinical trials have shown that improved glycemic control reduces the risk of progression of microalbuminuria to proteinuria, two recent clinical trials did not confirm this finding. We sought to reconcile the contradictory evidence by examining the dose-response relationship between hyperglycemia and progression of microalbuminuria to proteinuria in individuals with type 1 diabetes and microalbuminuria (n = 312) who were followed for 4 years with repeated assessments of urinary albumin excretion. Since 33 patients did not participate in follow-up (10.6%), data for 279 patients were analyzed. Urinary albumin excretion level worsened to proteinuria in 40 (4.1 per 100 person-years). To examine the dose-response relationship, baseline HbA1c was divided into four roughly equal groups using the cut points 8, 9, and 10%. The incidence rate varied significantly among the four groups (P = 0.008). Among those with HbA1c <8.0%, the incidence rate of progression was only 1.3 per 100 person-years, while it was 5.1, 4.2, and 6.7 per 100 person-years in the three other groups. We used generalized additive models to examine the dose-response curve using HbA1c as a continuous variable and found that the risk of progression rises steeply between an HbA1c of 7.5-8.5% and then remains approximately constant across higher levels. In conclusion, the results of this study suggest that, in patients with microalbuminuria, the risk of progression to overt proteinuria can be reduced by improved glycemic control only if the HbA1c is maintained below 8.5%. Moreover, below that value, the risk declines as the level of HbA1c decreases.

Maternal sensitivity during infancy and subsequent life events relate to attachment representation at early adulthood

A prospective longitudinal research study of 86 prematurely born children from birth to age 18 years provided empirical evidence for continuity from infancy experience to representations of attachment at age 18 years. Young adults whose representation of attachment was dismissing had been objectively observed during infancy, 16-17 years earlier, to receive less sensitive maternal care than those infants who were later judged at early adulthood to have secure or preoccupied representations. Infancy experience alone did not differentiate young adults with secure representations from those with preoccupied representations. Rather, adverse life events through age 12, particularly parental divorce, reduced the likelihood of secure representations and increased the likelihood of preoccupied representations. The absence of adverse life events did not increase the likelihood of security for those who had not experienced early sensitive caregiving.

Maternal sensitivity during infancy and subsequent life events relate to attachment representation at early adulthood

A prospective longitudinal research study of 86 prematurely born children from birth to age 18 years provided empirical evidence for continuity from infancy experience to representations of attachment at age 18 years. Young adults whose representation of attachment was dismissing had been objectively observed during infancy, 16-17 years earlier, to receive less sensitive maternal care than those infants who were later judged at early adulthood to have secure or preoccupied representations. Infancy experience alone did not differentiate young adults with secure representations from those with preoccupied representations. Rather, adverse life events through age 12, particularly parental divorce, reduced the likelihood of secure representations and increased the likelihood of preoccupied representations. The absence of adverse life events did not increase the likelihood of security for those who had not experienced early sensitive caregiving.

Randomized comparison of intravenous nitroglycerin and magnesium sulfate for treatment of preterm labor

OBJECTIVE

To compare the safety and efficacy of high-dose intravenous (IV) nitroglycerin with those of IV magnesium sulfate for acute tocolysis of preterm labor.

METHODS

Thirty-one women with preterm labor before 35 weeks' gestation were assigned randomly to IV magnesium sulfate or IV nitroglycerin for tocolysis. Preterm labor was defined as the occurrence of at least two contractions in 10 minutes, with cervical change or ruptured membranes. Acute tocolysis was defined as tocolysis for up to 48 hours. Magnesium sulfate was administered as a 4-g bolus, then at a rate of 2-4 g/h. Nitroglycerin was administered as a 100-microg bolus, then at a rate of 1- to 10-microg/kg/min. The primary outcome measure was achievement of at least 12 hours of successful tocolysis.

RESULTS

Thirty patients were available for analysis. There were no significant differences in gestational age, cervical dilation, or incidence of ruptured membranes between groups at the initiation of tocolysis. Successful tocolysis was achieved in six of 16 patients receiving nitroglycerin, compared with 11 of 14 receiving magnesium sulfate (37.5 versus 78.6%, P = .033). Tocolytic failures (nitroglycerin versus magnesium sulfate) were due to persistent contractions with cervical change or rupture of previously intact membranes (five of 16 versus two of 14), persistent hypotension (four of 16 versus none of 14), and other severe side effects (one of 16 versus one of 14). Maternal hemodynamic alterations were more pronounced in patients who received nitroglycerin, and 25% of patients assigned to nitroglycerin treatment had hypotension requiring discontinuation of therapy.

CONCLUSION

Tocolytic failures were more common with nitroglycerin than with magnesium sulfate. The hemodynamic alterations noted in patients receiving nitroglycerin, including a 25% incidence of persistent hypotension, might limit the usefulness of IV nitroglycerin for the acute tocolysis of preterm labor.

Obstetric postanesthesia care unit stays: reevaluation of discharge criteria after regional anesthesia

BACKGROUND

Obstetric patients may have long postanesthesia care unit (OB-PACU) stays after surgery because of residual regional block or other conditions. This study evaluated whether modified discharge criteria might allow for earlier discharge without compromising patient safety.

METHODS

Data were prospectively collected for 6 months for all patients (N=358) who underwent cesarean section or tubal ligation and recovered in the OB-PACU. Regional anesthesia was used in 94% of patients. The duration of anesthesia and PACU stays, the presence and treatment of events in the PACU, and the regression of neural blockade were recorded. Discharge from the OB-PACU required a 60-min minimum stay, stable vital signs, adequate analgesia, and ability to flex the knees. After completion of prospective data collection, events that kept patients in the PACU after 60 min were reevaluated as to whether patients needed to stay in the PACU for medical reasons. "Needed to stay" events included bleeding, cardiorespiratory problems, sedation, dizziness, and pain. "Safe to leave" conditions included pruritus, nausea, and residual neural blockade. The cumulative duration of OB-PACU stays not clearly justifiable for medical reasons was calculated.

RESULTS

Residual block and spinal opioid side effects accounted for the majority of "unnecessary" stays. Annually, 429 h of PACU time could have been saved using the revised criteria. Complications did not develop subsequently in any patient deemed "safe to leave."

CONCLUSIONS

In many obstetric patients, the duration of PACU stays could safely be shortened by continuing observation in a lower-acuity setting. This may result in greater flexibility and more efficient use of nursing personnel.

Intrathecal sufentanil produces sensory changes without hypotension in male volunteers

BACKGROUND

Intrathecally administered sufentanil is frequently associated with hypotension and sensory changes in women undergoing labor. In this study, the authors examined whether intrathecally administered sufentanil has similar effects in pain-free individuals with low concentrations of progesterone (i.e., male volunteers).

METHODS

Ten male volunteers were randomly assigned to receive an intrathecal injection of either 10 microg sufentanil or saline in a double-blind fashion. Blood pressure, heart rate, oxyhemoglobin saturation, and temperatures from the body core and skin of the calf and ipsilateral great toe were recorded. Cold and pin prick sensation, motor block, and visual analogue scores for sedation, pruritus, and nausea also were assessed. Current perception thresholds using the Neurometer current perception threshold instrument (Neurotron, Inc., Baltimore, MD) were determined for three frequencies (2,000, 250, and 5 Hz, corresponding to stimulation of Abeta, Adelta, and C fibers, respectively) on the upper and lower extremities.

RESULTS

Pruritus and sensory changes to pin prick and cold occurred in the sufentanil group but not the saline group. Neither group had a significant change in blood pressure, heart rate, oxyhemoglobin saturation, sedation, or core temperature. There was a clinically insignificant difference in the calf minus toe temperature index between the saline and sufentanil groups. There was a small increase in the current perception thresholds at 250 Hz in the sufentanil group.

CONCLUSIONS

Intrathecally administered sufentanil did not affect blood pressure in male volunteers. The other effects of sufentanil, however, were similar to those observed in women undergoing labor. This suggests that the hypotension occurring in these women after intrathecally administered sufentanil is secondary to relief of pain, rather than to a sympathectomy.

Anserine bursitis and non-insulin dependent diabetes mellitus

OBJECTIVE

To determine the relationship between non-insulin dependent diabetes mellitus (NIDDM), knee pain, and anserine bursitis, and its relation to sex, age, or body mass index (BMI).

METHODS

Ninety-four consecutive patients with NIDDM, 66 women and 28 men, and 57 nondiabetic patients, 36 women and 22 men, were examined at an outpatient clinic of a tertiary care hospital. Date of onset in patients with NIDDM was noted, and serum was analyzed for either hemoglobin A1C (HbA1C) or glycosylated hemoglobin (GHb) in 69 of these patients. Anserine bursitis was diagnosed if knee pain and tenderness at the bursal site were found on examination.

RESULTS

On examination 34 (36%) patients with NIDDM were found to have anserine bursitis. Of these, 31 (91%) were women and 3 (9%) were men (p < 0.05). Age, BMI, duration of diabetes, HbA1C or GHb, and age of onset of diabetes were found not to differ significantly between patients with and those without anserine bursitis.

CONCLUSION

A relationship exists between NIDDM, knee pain, and anserine bursitis unrelated to age, BMI, duration and control of diabetes, and age at the diagnosis of diabetes.

Intrathecal sufentanil for labor analgesia does not cause a sympathectomy

BACKGROUND

Intrathecal sufentanil (ITS) is frequently used to provide analgesia during labor. Decreases in blood pressure and sensory changes in this circumstance suggest that ITS may have a local anesthetic effect and thus cause a sympathectomy. To determine whether ITS given to laboring women causes a sympathectomy, the authors evaluated central and lower extremity temperature changes after ITS administration. These findings were compared with those in a control group of women having spinal anesthesia with bupivacaine for elective cesarean section in whom an extensive sympathectomy was expected.

METHODS

Twenty parturients classified as American Society of Anesthesiologists' physical status 1 or 2 had temperatures measured centrally, at the calf, and at the great toe at frequent intervals after receiving 10 microg ITS for labor analgesia (sufentanil group, n = 10), or hyperbaric bupivacaine 12 mg in their spinal anesthetic for cesarean section (bupivacaine group, n = 10). Calf-to-toe temperature indices (C-T) were calculated by subtracting toe temperature from calf temperature. A decrease in this index means that the toe had warmed compared with the calf and is an indication of vasodilation and a sympathectomy.

RESULTS

There was no significant change in the C-T indices or central temperature in the sufentanil group, but the C-T indices and central temperature decreased significantly in the bupivacaine group.

CONCLUSIONS

The decreases in the C-T index and central temperature in the bupivacaine group indicate the presence of a sympathectomy. The lack of change in the C-T indices and central temperature in the sufentanil group indicates that no significant vasodilation occurred. Therefore, the decrease in blood pressure seen after ITS administration for labor analgesia is unlikely to be the result of a sympathectomy.

Unusual spontaneous hepatic vein to paraumbilical vein shunt in a patient with Budd-Chiari syndrome and cirrhosis: a case report

A very unusual portosystemic shunt was identified using color flow Doppler sonography in an adult male with Budd-Chiari syndrome and cirrhosis secondary to a hypercoagulability state. Hepatofugal blood flow was demonstrated between the middle hepatic vein and a recanalized paraumbilical vein, resulting clinically in prominent periumbilical veins. The clinical and radiological features are described.

Changes in the position of epidural catheters associated with patient movement

BACKGROUND

Epidural catheter movement has been noted with change of patient position and can result in inadequate anesthesia. This study was designed to measure movement and to develop a technique that minimizes catheter displacement.

METHODS

In 255 parturients requesting epidural anesthesia for labor or cesarean section, a multiorificed lumbar epidural catheter was inserted with the patient in the sitting flexed position. The distance to the epidural space, length of catheter inserted, and amount of catheter position change as the patient moved from the sitting flexed to sitting upright and then to the lateral decubitus position were measured before the catheter was secured to the skin. Adequacy of analgesia, the need for catheter manipulation, and whether the patient was considered obese were noted. Data were grouped according to body mass index (BMI): < 25, 25-30, and > 30 kg/m2.

RESULTS

The groups did not differ with respect to the length of catheter initially inserted or changes in catheter position between initial taping and removal. The distance to the epidural space differed significantly among the groups, increasing with greater BMI. Catheters frequently appeared to be drawn inward with position change from the sitting flexed to lateral decubitus position, with the greatest change seen in patients with BMI > 30. Only nine catheters were associated with inadequate analgesia, four of which were replaced. No analgesic failures occurred in the BMI > 30 group. In patients judged by the anesthesiologist to be obese or to have an obese back, BMI was greater, and distance to the epidural space and the magnitude of catheter movement with position change were greater than in those who were not obese.

CONCLUSIONS

Epidural catheters moved a clinically significant amount with reference to the skin in all BMI groups as patients changed position. If catheters had been secured to the skin before position change, many would have been pulled partially out of the epidural space. To minimize the risk of catheter displacement, particularly in obese patients, we recommend that multiorificed catheters be inserted at least 4 cm into the epidural space and that patients assume the sitting upright or lateral position before securing the catheter to the skin.

Intrathecal sufentanil for labor analgesia: do sensory changes predict better analgesia and greater hypotension?

Sensory changes and hypotension occur after intrathecal sufentanil (ITS) is given during labor. The goal of this study was to determine whether sensory changes are predictive of hemodynamic changes or duration of pain relief. We also examined whether sensory and hemodynamic changes relate to the concentration of ITS administered. Forty-five ASA physical status I and II women in active labor were randomly assigned to receive 10 micrograms ITS diluted in either 1, 2, or 3 mL of normal saline (15 in each group). An observer blinded to treatment recorded verbal pain scores, blood pressure, and sensory changes to light touch, pinprick, and cold at frequent intervals. Excellent analgesia was obtained in 42 of 45 patients. There were no differences among the groups with respect to the number of patients with sensory changes, the duration of analgesia or sensory changes, the quality of analgesia, or the severity of hypotension. The groups were therefore combined for further analyses. Among this combined group, the duration of analgesia was 99 +/- 7 min (mean +/- SE). Cold, pinprick, and light touch sensation were decreased in 66%, 50%, and 33% of patients, respectively. Motor block was absent in all patients. The duration and quality of analgesia were similar in subjects with and without sensory changes. Systolic blood pressure decreased 23 +/- 2 mm Hg (P < 0.05) during the first 30 min after ITS, and six patients were given ephedrine. The magnitude of blood pressure change was not affected by the diluent volume or the presence of sensory changes. Because sensory changes were not predictive of the duration or quality of analgesia or the degree of hemodynamic change, we conclude that analgesia with ITS is predominantly mediated via spinal cord opioid receptors rather than by a local anesthetic-type conduction blockade.

Direct right atrial catheter insertion with video-assisted thoracic surgery

Chronic gastrointestinal disorders may require support with long-term total parenteral nutrition via a central venous catheter. Central venous access may be problematic because of infection or thrombosis of previous catheters. We report a case where video-assisted thoracic surgical catheter insertion directly into the right atrium provided a successful and safe method of long-term central venous access for parenteral nutrition.

Conservative therapy in an ERCP-induced abdominal abscess

We describe a 30 year-old man who presented with an abdominal abscess as an unusual complication of endoscopic retrograde cholangiopancreatography with papillotomy. His presenting symptom was recurrent vomiting, while fever, abdominal pain, and leukocytosis were not significant. The abscess was observed with repeated computerized tomographic scans and completely regressed with intravenous antibiotic treatment over a three week period, leading to complete remission.