Intravascular absorption syndrome : case report of a life-threatening complication during hysteroscopy

A 40-year old, healthy woman underwent hysteroscopic endometrial ablation with a bipolar electrocautery using 0.9% saline as distension fluid. After 45 minutes of surgery, arterial oxygen saturation decreased and liquid was obstructing the laryngeal mask. With an estimated total fluid deficit of 5000 mL, fluid overload was suspected and the patient's trachea was intubated. Furosemide was given intravenously and a urinary catheter was inserted. The intra-abdominal pressure, measured through the urinary catheter, was 28 mmHg. As ventilation became unfeasible, the patient became cyanotic and no clear pulse could be detected, cardiopulmonary resuscitation was started. In order to decrease the abdominal pressure, a laparotomy was performed and extracorporeal membrane oxygenation was started to increase the arterial oxygenation. After one week in the Intensive Care Unit, the patient was extubated and gradually recovered without further complications nor residual morbidity. The pathophysiological aspects of the evolution to severe pulmonary edema due to massive fluid translocation during operative hysteroscopy, and the rationale behind the successful interventions are being discussed. Close continuous monitoring of the amount of fluid deficit should be performed to avoid severe fluid overload during operative hysteroscopy. Extracorporeal membrane oxygenation can be life-saving to bridge the period of desaturation until standard treatment suffices to provide adequate oxygenation

Lower extremity near-infrared spectroscopy after popliteal block for orthopaedic foot surgery

BACKGROUND: Noninvasive measurement of cutaneous tissue oxygenation using near-infrared spectroscopy (NIRS) has become common in peri-operative care. Following institution of peripheral nerve blocks, neurovascular alterations in the blocked region have been described. OBJECTIVE: The primary aim of this study encompassed the assessment of the influence of a popliteal block on changes in regional oxygen saturation (SrO(2)), and the location of most prominent changes. METHOD: We conducted a prospective randomised controlled trial. Hundred twenty patients who received a popliteal block for foot surgery were included. Popliteal block was performed under echographic guidance. The patients were randomized in 3 groups according to the location of the SrO(2) electrodes on the legs. Bilateral SrO(2) measurements were performed simultaneously. SrO(2) in the operated leg and in the control leg was measured at baseline and 1, 5, 10, 15, and 30 minutes after the perineural injection. We quantified the evolution in SrO(2) by calculating over time the differences in SrO(2) values between the operated and control leg (=ΔSrO(2)). RESULTS: At 30 minutes, ΔSrO(2) increased significantly (p<0.05) at the plantar side of the foot (11.3% ± 2.9%), above the ankle (4.9% ± 1.3%) and the popliteal fossa (3.6% ± 1.2%). CONCLUSION: At 30 minutes after institution of the popliteal block, ΔSrO(2) was most prominent at the plantar side of the foot as compared with measurement performed above the ankle or under the knee

Managing the Prevention of In-Hospital Resuscitation by Early Detection and Treatment of High-Risk Patients

In hospitalized patients, cardiorespiratory collapse mostly occurs after a distinct period of deterioration. This deterioration can be discovered by a systematic quantification of a set of clinical parameters. The combination of such a detection system—to identify patients at risk in an early stage —and a rapid response team—which can intervene immediately—can be implemented to prevent life-threatening situations and reduce the incidence of in-hospital cardiac arrests outside the intensive care setting. The effectiveness of both of these systems is influenced by the used trigger criteria, the number of rapid response team (RRT) activations, the in- or exclusion of patients with a DNR code >3, proactive rounding, the team composition, and its response time. Each of those elements should be optimized for maximal efficacy, and both systems need to work in tandem with little delay between patient deterioration, accurate detection, and swift intervention. Dependable diagnostics and scoring protocols must be implemented, as well as the organization of a 24/7 vigilant and functional experienced RRT. This implies a significant financial investment to provide an only sporadically required fast intervention and sustained alertness of the people involved

COVID-19 symptoms at hospital admission vary with age and sex: results from the ISARIC prospective multinational observational study

Background: The ISARIC prospective multinational observational study is the largest cohort of hospitalized patients with COVID-19. We present relationships of age, sex, and nationality to presenting symptoms. Methods: International, prospective observational study of 60 109 hospitalized symptomatic patients with laboratory-confirmed COVID-19 recruited from 43 countries between 30 January and 3 August 2020. Logistic regression was performed to evaluate relationships of age and sex to published COVID-19 case definitions and the most commonly reported symptoms. Results: ‘Typical’ symptoms of fever (69%), cough (68%) and shortness of breath (66%) were the most commonly reported. 92% of patients experienced at least one of these. Prevalence of typical symptoms was greatest in 30- to 60-year-olds (respectively 80, 79, 69%; at least one 95%). They were reported less frequently in children (≤ 18 years: 69, 48, 23; 85%), older adults (≥ 70 years: 61, 62, 65; 90%), and women (66, 66, 64; 90%; vs. men 71, 70, 67; 93%, each P &lt; 0.001). The most common atypical presentations under 60 years of age were nausea and vomiting and abdominal pain, and over 60 years was confusion. Regression models showed significant differences in symptoms with sex, age and country. Interpretation: This international collaboration has allowed us to report reliable symptom data from the largest cohort of patients admitted to hospital with COVID-19. Adults over 60 and children admitted to hospital with COVID-19 are less likely to present with typical symptoms. Nausea and vomiting are common atypical presentations under 30 years. Confusion is a frequent atypical presentation of COVID-19 in adults over 60 years. Women are less likely to experience typical symptoms than men

Tracheal diverticulum as a cause of subcutaneous emphysema following positive-pressure ventilation

Pulse pressure variation (PPV) and stroke volume variation (SVV) are dynamic preload variables that can be measured noninvasively to assess fluid responsiveness (FR) in anesthetized patients with mechanical ventilation. Few studies have examined the effectiveness of predicting FR according to the definition of FR, and assessment of inconclusive values of PPV and SVV around the cut-off value (the "grey zone") might improve individual FR prediction. We explored the ability of noninvasive volume clamp derived measurements of PPV and SVV to predict FR using the grey zone approach, and we assessed the influence of multiple thresholds on the predictive ability of the numerical definition of FR. Ninety patients undergoing general surgery were included in this prospective observational study and received a 500 mL fluid bolus as deemed clinically required by the attending anesthesiologist. A minimal relative increase in stroke volume index (a dagger SVI) was used to define FR with different thresholds from 10-25%. The PPV, SVV, and SVI were measured using the NexfinA (R) device that employs noninvasive volume clamp plethysmography. The area under the receiver operator characteristic curve gradually increased for PPV / SVV with higher threshold values (from 0.818 / 0.760 at 10% a dagger SVI to 0.928 / 0.944 at 25% a dagger SVI). The grey zone limits of both PPV and SVV changed from 9-16% (PPV) and 5-13% (SVV) at the 10% a dagger SVI threshold to 18-21% (PPV) and 14-16% (SVV) at the 25% a dagger SVI threshold. Noninvasive PPV and SVV measurements allow an acceptable FR prediction, although the reliability of both variables is dependent on the intended increase in SVI, which improves substantially with concomitant smaller grey zones at higher a dagger SVI thresholds

A neuro-anatomically grounded scheme for LIA gives superior analgesia and comfort levels compared to epidural analgesia until seven days after total knee arthroplasty

LIA is an emerging alternative for patient-controlled epidural analgesia(PCEA) after total knee arthroplasty(TKA). LIA allows faster mobilisation, eliminates the risks of epidural catheters, and can hasten patient turnover. Conversely, PCEA provides reliable pain relief in the first days after this type of surgery. The purpose of this study was to evaluate the quality of antinociception, postoperative nausea & vomiting (PONY), and general comfort until 7 days postoperatively. 40 patients received PCEA and 41 received LIA. Patients were retrospectively asked for pain scores at the day of surgery(=D0), D2, and D7, PONV, and general comfort scores. Patients in the LIA group reported equal pain scores at DO, significantly better PONV scores and pain scores at D2 and D7. In addition to faster mobilisation and elimination of the risks and burden of an epidural catheter and PCEA, LIA delivers equal to better analgesia, and better PONY and general comfort scores

Local infiltration of anesthetics gives better results for pain and comfort scores then patient controlled anesthesia in total knee arthroplasty

Background : Local infiltration of anesthetics (LIA) is an upcoming alternative method for analgesia following total knee arthroplasty (TKA). It could replace patient controlled epidural anesthesia (PCEA). The advantages of LIA are faster mobilization, less risks compared to placement of an epidural catheter, and it increases patient care in a quantitative and qualitative way. On the other hand, PCEA provides prolonged analgesia postoperatively. The aim of this study was to compare the effects of LIA and PCEA on pain and comfort scores during the seven days following TKA. Methods : Two weeks after hospital dismissal, a questionnaire was sent to 116 patients who underwent TKA. Patients were asked for their pain scores on the day of surgery (=D0), two days after (=D2) and 7 days after (=D7). They were also asked about their general comfort, postoperative nausea and vomiting (PONV), vertigo and comfort urinating. The primary endpoint was pain at D7, secondary endpoints were pain on D0 and D2. and comfort scores. Results : Data of 81 patients were analyzed. 40 were provided with PCEA and 41 patients received LIA. Pain scores on D7 were significantly better in the LIA-group (18 [0-75] vs 38 [0-100] for LIA and PCEA, respectively (p=0.01)). Pain scores on D2 were also significantly better in the LIA group, whereas no difference in pain scores was seen on D0. There was less PONV on D0 and less discomfort urinating on D7 in the LIA group. Other scores showed no significant differences between the two groups. Conclusion : LIA showed in lower pain scores and improved comfort scores, compared to PCEA

Effect of intravenous clonidine on postoperative agitation and recovery time after tonsillectomy

Tonsillectomy is routinely performed in most hospitals, both in adult and pediatric patients. A main objective of anesthesia care for these procedures is swift and comfortable recovery, permitting rapid discharge from the Post Anesthesia Care Unit (PACU). In preventing agitation, overall experience as well as rebleeding risk and the length of stay (LOS) in the PACU stand to improve. Clonidine is known for having an anxiolytic, sedative and analgesic effect, as well as for reducing postoperative vomiting in children. At our department, anesthesia consists of propofol/sufentanil/ sevoflurane anesthesia, and paracetamol/diclofenac analgesia. Some anesthetists routinely give additional clonidine 1 mcg.kg(-1) to children for tonsillectomy, others never do. This retrospective study evaluates the effect of intravenous clonidine on agitation and recovery time following tonsillectomy in different age groups. Out of all consecutive tonsillectomy cases between 1/2016 and 11/2018, a convenience sample of 473 patients was selected and included in this retrospective analysis. Of 473 included patients, 383 did not receive clonidine perioperatively and 90 did. Agitation was defined as a Ramsay Sedation Scale score of 1. In pediatric patients (<18 years), clonidine produced a relative risk reduction of agitation of 35.7% (p=0.235). We found a reduction in LOS in both pediatric and adult patients, of 5 and 11 minutes respectively (p=0.242 and p=0.262). Clonidine seems to reduce agitation and LOS in the PACU when administered perioperatively in patients undergoing tonsillectomy. A sample size calculation shows 463 patients are required in each group to achieve power of 95%. Because of the retrospective nature of our study, with its inherent risk of confounding factors, our findings should be confirmed in prospective studies