Bupivacaine crystal deposits after long-term epidural infusion

The case of a 45-year-old male patient (body weight 52kg, height 1.61m) with a locally invasive gastric carcinoma infiltrating into the retroperitoneal space is reported. Because of severe cancer pain a tunnelled thoracic epidural catheter (EC) was placed at thoracic spinal level 7/8 and a local anesthetic (LA) mixture of bupivacaine 0.25 % and morphine 0.005 % was infused continuously at 6mlh−1. To optimize pain therapy the concentration was doubled (bupivacaine 0.5 %, morphine 0.01 %) 3 months later but the infusion rate was reduced to 3mlh−1 thus the total daily dose did not change. The patient died 6 months after initiation of the epidural analgesia from the underlying disease. The total amount of bupivacaine infused was 69g and of morphine 1.37g. The patient never reported any neurological complications. The autopsy revealed large white crystalline deposits in the thoracic epidural space which were identified as bupivacaine base by infrared spectrometry. Morphine could not be detected. A histological examination showed unreactive fatty tissue necrosis within the crystalline deposits but nerve tissue could not be identified. It is concluded that the bupivacaine crystalline deposits arose due to precipitation but the clinical significance with regard to sensory level and neuraxial tissue toxicity is unknow

Postoperative Qualitätsanalyse bei Kindern: Schmerz sowie postoperative Übelkeit und Erbrechen

Zusammenfassung: Hintergrund: Zur Evaluation des postoperativen Behandlungskonzepts beteiligt sich das Kinderspital Luzern am Projekt für Qualitätsanalyse in PONV ("postoperative nausea and vomiting", postoperative Übelkeit und Erbrechen) und Schmerzen bei Kindern (QUIPSi; i: "infants"). Erste Resultate und eine Möglichkeit der postoperativen Qualitätsanalyse bei Kindern werden dargestellt. Dabei waren zentrale Fragen entscheidend: Ist das hausinterne postoperative Behandlungskonzept adäquat genug, und ist QUIPSi ein hilfreiches postoperatives Qualitätsevaluationsprojekt? Material und Methoden: Innerhalb von 1,5Jahren wurden 460Kinder im Alter von 4 bis 17Jahren bezüglich Schmerzen, Wunsch nach mehr Schmerzmitteln, Schmerzmitteldosis und PONV am 1.postoperativen Tag mithilfe eines standardisierten Fragebogens erfasst. Ergebnisse: Die teilnehmenden Kinder ließen sich in 5 ambulante Operationsgruppen (Hernie, Knochen, Metallentfernung, Penis, Weichteil) und 9 stationäre (Appendektomie, Knochen, Metallentfernung, Orchidopexie, Kombinationsoperation: Orchidopexie und Hernienoperation oder Zirkumzision, Otoplastik, Tonsillektomie, Trichterbrustoperation, Weichteil) einteilen. Folgende Operationsgruppen gaben insuffizient behandelte Maximalschmerzen (Skala nach Hicks 0-10) und/oder den Wunsch nach mehr Schmerzmitteln an: ambulant versorgte Kinder: Zirkumzision 5,1/19 %, stationär versorgte Kinder: Appendektomie 6,5/43 %, Tonsillektomie 6,4/32 %, Trichterbrustoperation 7,7/33 %, Orchidopexie 4,2/19,4 % und Otoplastik 3,1/22,2 %. Die Ursachen hierfür waren ungenügende postoperative Schmerzmittelverabreichung trotz der maximal verordneten Tagesdosis sowie wahrscheinlich verspätete Verabreichung der Schmerzmittel. Die Inzidenz des PONV fiel bei stationär behandelten Kindern (Übelkeit 14-50 %/Erbrechen 0-37 %) höher aus als bei ambulant versorgten Kindern (Übelkeit 0-29 %/Erbrechen 3-17 %). Schlussfolgerung: Besonders die Kinder mit dem Wunsch nach mehr Schmerzmitteln sowie einer hohen PONV-Inzidenz der stationären Operationsgruppe bedürfen einer qualitativen Verbesserung des postoperativen Behandlungskonzepts. Durch QUIPSi werden unerkannte Schwächen im postoperativen Behandlungskonzept aufgedeckt; es trägt zu deren Vermeidung bei und ist ein bereicherndes Werkzeug in der Führung eines Klinikbetrieb

Enhancing Phenolic Maturity of Syrah with the Application of a New Foliar Spray

Climate change is inducing earlier grape ripening, especially in warm vintages. This phenomenon isresulting in unbalanced wines an alcohol concentration that is too high and titratable acidity that is low,along with a high pH level without the desired level of phenolic maturity. Final wine quality notably dependson the phenolic composition of the grapes and the extractability of these compounds. This research wasdesigned to test a new foliar spray, called LalVigne® MATURE, for its capacity to create a balance betweensugar development and phenolic maturity. It is a formulation of 100% natural, inactivated wine yeastderivatives. This foliar spray was tested on Syrah vines in two vintages (2012 and 2013) in a cool-climatewine region (Eger, Hungary). The spray acted as an elicitor, stimulating the synthesis of several secondarymetabolites. The changes in anthocyanin extractability and texture characteristics of the grape berrieswere followed during ripening. Experimental wines were made at three separate harvest times in eachvintage. Standard analytical parameters were evaluated for grapes and wines, as well as for resveratrol.Grapes from the treated vines had thicker skins than the controls at all sampling dates in both vintages.The phenolic potential (especially anthocyanin concentration and extractability) of the foliar spray-treatedgrapes was greatly improved. Our experiment showed that phenolic ripening can be enhanced using thefoliar spray, and that its application was useful in different vintages

The effect of yeast on the anthocyanin characteristics of fermented model solutions

The sensory quality of red wines is basically determined by the colour, which depends on the amount and on the evolution of anthocyanins and other phenolic compounds extracting from the berries into the wine during wine-making. The anthocyanin-monomers are responsible for the development of the red colour, and their acylated derivatives provide stability for the colour of the wines. The anthocyanin profile of wines is affected by several factors: the grape variety, the conditions during wine-making, and also the yeast culture used for the fermentation. In our experiments a self-compiled model solution was fermented by spontaneous fermentation, as well as by four commercial yeasts under laboratory conditions. After fermentation total polyphenolics, anthocyanins, anthocyanin monomer profile, colour intensity, hue, and the ratio of polymeric anthocyanins were studied. Our results show that the spontaneous yeast fermentation resulted in a higher anthocyanin concentration in the fermented model solution, but the commercial yeast strains provided a more advantageous colour characteristic compared to the spontaneous fermentation. After the spontaneous fermentation less sediment was left than in the commercial yeast fermented samples