Rhabdomyolysis-induced acute renal failure after morphine overdose--a case report

The 39-year-old male in this report was a victim of C4 spinal cord injury for 7 years. He was regularly followed up at our pain clinic and psychiatric out-patient department (OPD) for treatment of his chronic pain with morphine, anticonvulsant and sedatives. At the night of December 15, 1997, he took approximately 0.1 gm of morphine and a certain number of flurazepam pills. On the next day, he experienced numbness and paresis in both legs in association with painful swelling of both thighs. Then he sought medical advice at our hospital and was admitted for investigation on December 20, 1997. Laboratory examination revealed elevated creatine kinase activity, increased urine myoglobin concentration and raised plasma creatinine, signifying the development of acute muscle damage. The excreted urine morphine concentration was as high as 6,384 ng/mL. Increased PYP uptake in the proximal portion of both thighs was noted on muscle scan. These abnormalities were resolved gradually over two weeks under conservative treatment. Morphine-induced rhabdomyolysis complicated by acute renal failure was highly suspected.

Role of right hepatic lobectomy in the treatment of isolated right-sided hepatolithiasis

BACKGROUND

The role of right hepatic lobectomy is evaluated in the treatment of selected patients with isolated right-sided hepatolithiasis.

METHODS

During the past 7 years right hepatic lobectomy was performed in five patients who had isolated right-sided hepatolithiasis. The rationale and indications of this procedure are discussed. The efficacy of preoperative evaluations, the operative findings, and the operative results are analyzed.

RESULTS

All the patients were female with a mean age of 49.2 years (range, 33 to 63 years). The main symptoms were upper abdominal pain (n = 5), fever (n = 4), and jaundice (n = 2). The mean operative time was 166.4 minutes, and the mean blood loss was 880 ml. The complete stone clearance rate was 100%. No operative deaths occurred. Right subphrenic abscess with reactive pleural effusion developed in two patients. Echo-guided percutaneous drainage was applied to one patient, and no surgical intervention was needed. The mean follow-up period from the treatment was 13.4 months (range, 6 to 18 months). During the follow-up period no stone recurrence was found.

CONCLUSIONS

Right hepatic lobectomy is indicated in patients who have localized right-sided hepatolithiasis with irreversible biliary stricture involving the right hepatic duct, an atrophied right lobe of the liver, multiple cholangitic abscesses, or possible presence of cholangiocarcinoma. Preoperative evaluations, including cholangiography, abdominal ultrasonography, and computed tomography, are important for the accurate selection of patients and successful treatment.

A simple, secure and universal pancreaticojejunostomy following pancreaticoduodenectomy

Although the operative mortality of pancreaticoduodenal resection has decreased recently, the operative morbidity resulting from a leaking pancreatic anastomosis remains high. We described our experience in 50 consecutive cases with a simple, secure end to side pancreaticojejunostomy. We used a paediatric nasogastric tube in the pancreatic remnant duct as a temporary external pancreatic drain. There were 29 men and 21 women ranging from 12 to 84 years with a median age of 61 years. Forty-two patients underwent a standard Whipple procedure and eight a pylorus preserving pancreaticoduodenectomy. Average operating time was 270 minutes with a range of 170 to 480 minutes. The pancreaticojejunostomy could be constructed in a mean of 8 minutes. Intraoperative blood loss ranged from 150 to 3500 mL with a mean of 910 mL. Twenty-five patients (50%) received no blood transfusion. The consistency of the pancreatic remnant was hard in 12 patients (24%) and normal in 38 patients (76%). The pancreatic duct was dilated (> 4 mm) in 15 patients (30%). There was no operative mortality and only three (6.0%) minor leaks from the pancreatic anastomosis which healed spontaneously. It was difficult to determine if the leaks were related to the consistency of the pancreatic remnant, the size of the pancreatic duct, the amount of intraoperative blood loss, operating time, sex of the patient or experience of the surgeon, as there were only three leaks. We concluded that our technique for pancreaticojejunal anastomosis following pancreaticoduodenectomy was safe and applicable to, standard Whipple or pylorus preserving pancreaticoduodenectomy, small or dilated pancreatic ducts, normal or fibrotic pancreas.

Co-administration of midazolam decreases propofol dose during anesthesia in endoscopic laryngeal microsurgery

BACKGROUND

Propofol is commonly used in total intravenous anesthesia (TIVA) for brief surgical procedures because it offers rapid recovery and has fewer side effects. However, concomittent use of other adjuvant agents has been considered so that the same anesthetic effects can be achieved at lower doses of propofol which is more expensive without compromising rapid recovery and increasing the adverse effects. This study was therefore designed to evaluate the co-administration of midazolam and propofol during anesthesia for endoscopic microsurgery and test its influences on the consumption of propofol and the quality of anesthesia.

METHODS

Forty-two patients receiving selective endoscopic microsurgery were enrolled in this study. All patients received high frequency jet ventilation (HFJV) under TIVA. The control group (n = 21) received propofol (20 mg/5 s) during induction and 10 mg/kg/h as maintenance. The study group (n = 21) received midazolam (0.06 mg/kg) and propofol (20 mg/5 s) for induction with propofol 8 mg/kg/hr for maintenance. Doses of propofol, vital signs, recovery time, post-anesthetic high cortical function, and adverse events were evaluated and compared.

RESULTS

Co-administration of midazolam and propofol in TIVA could reduce the induction dose and the total dose of propofol by 51% and 26% respectively but still achieve the same anesthetic effects. Vital signs and recovery were not influenced, and incidence of adverse effects did not increase.

CONCLUSIONS

Our result suggests that co-administration of midazolam and propofol in TIVA appears to be safe, effective, and economic alternative to that with propofol alone. The effects were synergic but side effects were not.

Will epidural with light general anesthesia increase the incidence of awareness with recall or dream postoperatively

BACKGROUND

The incidence of awareness with recall during general combined with epidural anesthesia has not been previously reported. The purpose of this study was to quantify the incidence.

MATERIALS & METHODS

One hundred patients were divided into two groups. Group 1 (N = 50) received general anesthesia (GA), Group 2 (N = 50) received GA and epidural anesthesia (EA) intraoperatively. No premedication was given. These patients were induced with thiopentol (5 mg/kg) or propofol (2.0 mg/kg) and anectine (1.2 mg/kg) for smooth tracheal intubation and maintained with N2O:O2 = 1.5:1.5, and isoflurane and muscle relaxant of either pavulon or atracurium. No sedatives was given. Before anesthesia, we introduced an epidural catheter into the group 2 patients. After induction, headphones with soft music were given to the patients, in both groups, throughout the operation. 20-36 hours after operation or when the patients were fully awake, we asked the patients if they had heard anything or dreamed intraoperatively.

RESULTS

We found that not one of the one hundred patients heard anything or dreamed intraoperatively.

Electrodeposited Defect Chemistry Superlattices

Nanometer-scale layered structures based on thallium(III) oxide were electrodeposited in a beaker at room temperature by pulsing the applied potential during deposition. The conducting metal oxide samples were superlattices, with layers as thin as 6.7 nanometers. The defect chemistry was a function of the applied overpotential: High overpotentials favored oxygen vacancies, whereas low overpotentials favored cation interstitials. The transition from one defect chemistry to another in this nonequilibrium process occurred in the same potential range (100 to 120 millivolts) in which the rate of the back electron transfer reaction became significant. The epitaxial structures have the high carrier density and low electronic dimensionality of high transition temperature superconductors.

Scanning Tunneling Microscopy of Electrodeposited Ceramic Superlattices

Cleaved cross sections of nanometer-scale ceramic superlattices fabricated from materials of the lead-thallium-oxygen system were imaged in the scanning tunneling microscope (STM). The apparent height differences between the layers were attributed to composition-dependent variations in local electrical properties. For a typical superlattice, the measured modulation wavelength was 10.6 nanometers by STM and 10.8 nanometers by x-ray diffraction. The apparent height profile for potentiostatically deposited superlattices was more square than that for galvanostatically deposited samples. These results suggest that the composition follows the applied potential more closely than it follows the applied current. The x-ray diffraction pattern of a superlattice produced under potential control had satellites out to the fourth order around the (420) Bragg reflection.

[Etiologies of unilateral block of epidural anesthesia: a case report]

We would like to present a patient, who was a 60 years old man, 160 cm tall, weighing 55 kg, which received debridement for his pressure sores under epidural anesthesia. While inserting the Touhy needle, there was obvious loss of resistance at the level of 9 cm below the skin. When the test dose was injected, the compliance was good. Later, the anesthesia behaved as unilateral block. After the operation, the computerized tomography revealed the epidural catheter was between the facia of right psoas major muscle. Form this case, there were some lesions: (1) The distance from the skin to the lumbar dura mater is seldom longer than 7 cm. (2) The obvious loss-of-resistance and good compliance of test dose are not the guarantee of epidural anesthesia. (3) The psoas block may be another cause of unilateral block of lumbar epidural anesthesia.