Multimodal therapies for postoperative nausea and vomiting, and pain

Postoperative nausea and vomiting (PONV) and pain are two of the major concerns for patients presenting for surgery. The causes of PONV are multifactorial and can largely be categorized as patient risk factors, anaesthetic technique, and surgical procedure. Antiemetics work on several different receptor sites to prevent or treat PONV. This is probably why numerous studies have now demonstrated that using more than one antiemetic is usually more effective and results in fewer side-effects than simply increasing the dose of a single antiemetic. A multimodal approach to PONV should not be limited to drug therapy alone but should involve a holistic approach starting before operation and continuing intraoperatively with risk reduction strategies to which are added prophylactic antiemetics according to the assessed patient risk for PONV. With the increasing understanding of the pathophysiology of acute pain, especially the occurrence of peripheral and central hypersensitization, it is unlikely that a single drug or intervention is sufficiently broad in its action to be adequately effective, especially with moderate or greater pain. Although morphine and its congeners are usually the foundation of pain management regimens, as their dose increases so does the incidence of side-effects. Thus, the approach for the management of acute postoperative pain is to use multiple drugs or modalities (e.g. regional anaesthesia) to maximize pain relief and reduce side-effects.

Disseminated adenovirus infection in renal transplant recipients: the role of cidofovir and intravenous immunoglobulin

Disseminated adenovirus (ADV) infection in solid organ transplant patients is associated with high mortality. Limited studies have shown benefit from using cidofovir (CDV), as well as intravenous immunoglobulin (IVIG). In this study, we report 2 renal transplant patients who presented with fever and pulmonary infiltrates. Both patients continued to worsen despite antibiotic therapy. Bronchoalveolar lavage viral culture and serum polymerase chain reaction (PCR) were positive for ADV. Patients were treated with CDV, IVIG, and reduction in immunosuppression. A progressive decline in serum ADV DNA by PCR correlated with clinical improvement and pulmonary infiltrates improved. Both patients recovered. Allograft function was preserved although reversible acute kidney injury was observed in both patients. To the best of our knowledge, this is the first successful use of CDV and IVIG in renal transplant patients with disseminated ADV infection.

Normouricemia in the syndrome of inappropriate antidiuretic hormone secretion

Hyponatremia is seen in 40% to 60% of hospitalized acquired immune deficiency syndrome (AIDS) patients. The syndrome of inappropriate antidiuretic hormone secretion (SIADH) and volume contraction are the most common causes. The serum uric acid level can be used to distinguish between these two causes of hyponatremia. Hypouricemia is the rule in SIADH, whereas hyperuricemia commonly accompanies volume contraction. This report presents an AIDS patient with SIADH and normouricemia secondary to pyrazinamide and ethambutol.

Renal hemorrhage in polyarteritis nodosa: diagnosis and management

We report a patient with biopsy-proven polyarteritis nodosa with massive hemorrhage from presumed interlobar artery rupture. The use of interventional radiology techniques such as embolization are discussed in the acute management of such patients. Embolization by interventional radiology should be considered a useful alternative to surgery in these patients. The utility of angiography as a diagnostic and therapeutic tool is demonstrated in this case.

Incidence and risk factors for early small bowel obstruction after celiotomy for penetrating abdominal trauma

The reported overall incidence of postoperative Small Bowel Obstruction (SBO) is 0.69 per cent. This study examined the incidence and risk factors for early postoperative SBO for penetrating abdominal trauma (PAT), with early SBO defined as SBO within 6 months of operation. This was a prospective cohort study of patients admitted to a Level 1 Trauma Center from 5/91 to 12/93 who required celiotomy for PAT. Patients were followed at least 6 months for readmission for SBO to be considered evaluable. Of 341 patients undergoing celiotomy for PAT and surviving to discharge, 298 (87.4%) were evaluable. The overall incidence of early SBO was 7.4 per cent and varied between 2.3 per cent (nontherapeutic celiotomy) and 10.8 per cent (small/large bowel injury). All patients with celiotomy for PAT are at increased risk for early SBO compared with elective surgery patients. Those with small/large bowel penetration or gunshot wounds are at the highest risk. Previous abdominal surgery is not a risk factor for early SBO in PAT patients. Surgeons and Managed Care case managers should devote special attention to close follow-up in PAT patients, particularly those with the risk factors identified in this study.