Cardiac pacing in patients with a cervical spinal cord injury

Study design: Retrospective medical record review. Objectives: To compare patients, admitted to an intensive care unit (ICU) with an acute cervical spinal cord injury (SCI) and documented motor deficit, who did, with those who did not, require a cardiac pacemaker. Setting: South Australian Tertiary Referral Intensive Care and Spinal Injury Unit. Methods: Retrospective medical record review and data set linkage. Results: From 1995 to 2007, 465 patients sustained a cervical SCI. Of these, 30 (6.5%) were admitted to ICU with a clinically assessable motor deficit and 3 (0.6% of all patients, or 10% of those admitted to ICU) required a cardiac pacemaker. All three patients had a cervical SCI, C5 (American Spinal Injury Association A) tetraplegia, and required invasive mechanical respiratory and inotropic support and a tracheostomy for weaning. Two patients (66%) were discharged alive to rehabilitation. Patients requiring a pacemaker had bradycardic episodes over a longer period (11 vs 4 days, P¼0.01), a trend towards a later onset of bradycardia (8 vs 1.5 days, P¼0.05) and a longer ICU length of stay (37 vs 10 days, P¼0.02). Conclusion: Patients with a cervical SCI requiring a cardiac pacemaker are characterized by a higher level of SCI injury and motor loss, require mechanical respiratory and inotropic support, a tracheostomy to wean, and bradycardic episodes of a later onset and over a longer period of time. These findings suggest that such patients should be managed at hospitals with specialized acute spinal injury, intensive care and cardiac pacemaker services.P Rangappa, J Jeyadoss, A Flabouris, JM Clark and R Marshal

Operative exposure and management of axillary vessel injuries

Axillary vessel injuries are uncommon and challenging injuries encountered by trauma surgeons. Proximity of this vessel to other adjacent veins including the axillary vein, brachial plexus and the osseous structures of the shoulder and upper arm account for a large number of associated injuries. Systematic review of the literature, with emphasis on the diagnosis, treatment and outcomes of these injuries, incorporating the authors' experience. Although uncommon, axillary arterial injuries can result in significant morbidity, limb loss and mortality. Early diagnosis and timely repair of the artery leads to good outcomes

A consensus document on bowel preparation before colonoscopy: Prepared by a Task Force from the American Society of Colon and Rectal Surgeons (ASCRS), the American Society for Gastrointestinal Endoscopy (ASGE), and the Society of American Gastrointestinal

Colonoscopy is the most commonly used technique for inspection of the colonic mucosa. The safety and effectiveness of colonoscopy in identifying important colonic pathology is directly impacted by the quality of the bowel preparation performed in anticipation of the procedure. Physicians favor preparations associated with the best patient compliance to achieve the best results. Patients favor preparations that are low in volume, palatable, have easy to complete regimens, and are reimbursed by health insurance or are inexpensive. Both patients and physicians favor preparations that are safe to administer in light of existing comorbid conditions and those that will not interact with previously prescribed medications. Aqueous NaP solutions, NaP tablets, and PEG solutions, especially low-volume solutions, are all accepted and well tolerated by the majority of patients undergoing bowel preparation for colonoscopy. Physicians are advised to select a preparation for each patient based on the safety profile of the agent, NaP or PEG, in light of the overall health of the patient, their comorbid conditions, and currently prescribed medications. In certain circumstances, such as bowel preparation in children and some elderly patients, patients with renal insufficiency, and those with hypertension who are receiving ACE inhibitors or ARBs, it may be advisable to adhere to PEG-based solutions because of the risks of occult physiologic disturbances that may potentially contraindicate the use of NaP-based regimens. A variety of other preparations, none of which seem as popular because of inferior efficacy and/or patient acceptance, remain available for use in other circumstances in which bowel preparation is necessary. Many adjuncts to bowel preparation have been proposed but remain largely inefficacious and therefore cannot be recommended for routine use