Anaesthetic management of a patient with sick sinus syndrome for exploratory laparotomy

Sick sinus syndrome is a generalised abnormality of cardiac impulse formation that may be caused either by an intrinsic disease of the sinus node, which makes it unable to perform its pacemaking function, or by extrinsic factors. It commonly affects elderly persons. While the syndrome can have many causes, it usually is idiopathic. Abnormalities encompassed by this syndrome include sinus bradycardia, sinus arrest or exit block, combinations of sinoatrial and atrioventricular nodal conduction disturbances and atrial tachyarrhythmias. Diagnosis of sick sinus syndrome can be difficult because of its nonspecific symptoms and elusive findings on an electrocardiogram or a Holter monitor. Here, we present the perioperative management of an elderly patient with sick sinus syndrome with seminoma of undescended testis posted for exploratory laparotomy.Keywords: sick sinus syndrome; elderly; exploratory laparotomy; temporary pacemaker insertio

Prediction of arterial pressure increase after fluid challenge

<p>Abstract</p> <p>Background</p> <p>Mean arterial pressure above 65 mmHg is recommended for critically ill hypotensive patients whereas they do not benefit from supranormal cardiac output values. In this study we investigated if the increase of mean arterial pressure after volume expansion could be predicted by cardiovascular and renal variables. This is a relevant topic because unnecessary positive fluid balance increases mortality, organ dysfunction and Intensive Care Unit length of stay.</p> <p>Methods</p> <p>Thirty-six hypotensive patients (mean arterial pressure < 65 mmH) received a fluid challenge with hydroxyethyl starch. Patients were excluded if they had active bleeding and/or required changes in vasoactive agents infusion rate in the previous 30 minutes. Responders were defined by the increase of mean arterial pressure value to over 65 mmHg or by more than 20% with respect to the value recorded before fluid challenge. Measurements were performed before and at one hour after the end of fluid challenge.</p> <p>Results</p> <p>Twenty-two patients (61%) increased arterial pressure after volume expansion. Baseline heart rate, arterial pressure, central venous pressure, central venous saturation, central venous to arterial PCO₂difference, lactate, urinary output, fractional excretion of sodium and urinary sodium/potassium ratio were similar between responder and non-responder. Only 7 out of 36 patients had valuable dynamic indices and then we excluded them from analysis. When the variables were tested as predictors of responders, they showed values of areas under the ROC curve ranging between 0.502 and 0.604. Logistic regression did not reveal any association between variables and responder definition.</p> <p>Conclusions</p> <p>Fluid challenge did not improve arterial pressure in about one third of hypotensive critically ill patients. Cardiovascular and renal variables did not enable us to predict the individual response to volume administration.</p> <p>Trial registration</p> <p>ClinicalTrials.gov: <a href="http://www.clinicaltrials.gov/ct2/show/NCT00721604">NCT00721604</a>.</p

Association of severe hypertension with pneumonia in elderly patients with acute ischemic stroke

Pneumonia is one of the most frequent complications in elderly patients with acute ischemic stroke. Although severe hypertension is often observed in the early phase of acute stroke, there are few studies of acute hypertension as a factor influencing the incidence of stroke-associated pneumonia (SAP) in elderly subjects with acute ischemic stroke. To assess the association of acute phase blood-pressure elevation with the incidence of SAP, we compared 10 elderly patients with acute ischemic stroke complicated with severe hypertension (⩾200/120 mm Hg) with 43 patients with moderate hypertension (160–199/100–119 mm Hg), as well as with 65 control normotensive or mildly hypertensive (<160/100 mm Hg) controls on admission. Data were collected on known risk factors, type of ischemic stroke and underlying chronic conditions. The significance of differences in risk factors was analyzed using univariate and multivariate comparisons of 38 SAP cases and others, 8 SAP death cases and others, and 28 patients with poor outcome associated with in-hospital death or artificial feeding at discharge and others. After adjustment for potential confounding factors, the relative risk estimates for SAP, SAP death and poor outcome were 2.83 (95% confidence interval 1.14–7.05), 5.20 (1.01–26.8) and 6.84 (1.32–35.4), respectively, for severe hypertension relative to normotensive or mildly hypertensive controls. We conclude that severe hypertension on admission is an independent predictive factor for SAP in elderly patients with acute ischemic stroke

Review Article - Anesthesia for dermatological surgery

Knowledge of local anesthesia is critically important to perform dermatological surgery. Local anesthetics when used judiciously are extremely safe and allow dermatologists to perform a variety of procedures. This article aims to provide an updated review of local anesthesia and local anesthetic drugs. Side effects of local anesthetics and techniques of regional anesthesia are discussed and some commonly used nerve blocks are explained. A detailed knowledge of the pharmacology of local anesthetics aids in optimal therapeutic use, and in prevention, early diagnosis and management of their toxicities by the clinician

Toxic epidermal necrolysis and agranulocytosis: Rare adverse effects of ciprofloxacin

Ciprofloxacin is one of the most commonly used antibacterial agents with relatively few side effects. Serious adverse reactions reported with ciprofloxacin are rare with an incidence of 0.6%. Recently we came across two rare adverse effects of ciprofloxacin, viz. toxic epidermal necrolysis and agranulocytosis. To our knowledge, a total of seven cases have been reported in the literature documenting an association between oral ciprofloxacin administration and toxic epidermal necrolysis. One case of granulocytopenia, four of pancytopenia and fifteen of leucopenia worldwide have been reported. With the use of ciprofloxacin becoming more and more widespread, these two rare but fatal complications of ciprofloxacin should be borne in mind

Case Report-Variant of Vohwinkel's syndrome

A 28-year-old female born to consanguineous parents, presented with progressive palmoplantar keratoderma since the age of six months and a constricting band on right fourth finger of one year duration. There was history of similar complaints being present in two other family members. Associated clinical findings included starfish-shaped cornified plaques on knuckles, resorption of distal phalanges and keratotic plaques on elbows, groins and knees. The patient was mentally sound and had normal audiometry. Biopsy from hyperkeratotic plaque showed hyperkeratosis, parakeratosis, increased granular layer and papillomatosis. Gene mapping for loricrin mutation was found to be negative

Role of efflux pump inhibitors on the antibiofilm efficacy of calcium hydroxide, chitosan nanoparticles, and light-activated disinfection

10.1016/j.joen.2011.06.017Journal of Endodontics37101422-1426JOEN

Comparison of Bolus Phenylephrine, Ephedrine and Mephentermine for Maintenance of Arterial Pressure during Spinal Anesth

INTRODUCTION: Hypotension is common following spinal anesthesia. Various vasopressors have been indicated to prevent it. The study compares three such agents namely phenylephrine, ephedrine and mephentermine. METHODS: The study included 90 patients undergoing elective and emergency cesarean section who developed hypotension following subarachnoid blockade. Parturient were randomly divided into three groups each group had 30 patients. Group P received bolus of Phenylephrine 25 microgram, where as group E received Ephedrine 5mg and Group M received Mephentermine 6mg. RESULTS: It was found that rise of blood pressure was significantly higher in case of phenylephrine group in first six minutes, after the bolus, there was significant reduction in the heart rate in phenylephrine group, but there was tachycardia following administration of bolus ephedrine and mephenteramine. Neonatal APGAR score were similar in all three groups. CONCLUSIONS: All three drugs maintained hemodynamics within 20 percent of the baseline values on intravenous administration. Keywords: APGAR, ephedrine, hypotension, mephentermine, phenylephrine, spinal anesthesia