Immediate Postoperative Period Research Articles

Effect of Preemptive Multimodal Analgesia Regimen on Post-operative Epidural Demand Boluses in Lower Limb Orthopaedic Surgeries.

Introduction Excruciating pain is associated with lower limb orthopaedic surgeries involving femoral shaft fractures. Postoperative pain management is still ineffective in low-resource settings where the use of epidural and opioid-free analgesia is impractical. Literature is scarce with respect to the effect of a preemptive multimodal analgesia regimen on the requirement of postoperative epidural demand boluses.Hence, the present study aimed to evaluate the effectof pre-emptive multimodal analgesia in reducing the requirement of epidural demand boluses postoperatively, and to find out the time required to receive the first epidural bolus. Material and methods This double-blinded randomized control study included 48 subjects. Patients aged 18-60 years with lower limb fractures requiring surgery under combined spinal-epidural anesthesia were included. Patients were divided into two groups through random allocation. Group A: Preemptive multimodal group received intravenous paracetamol 1 g, IV diclofenac 75 mg diluted in 100ml NS, IV tramadol 50mg diluted in 100ml NS and tab pregabalin 75 mg orally, 30 mins before surgery. Group B:Placebo group received 3 pints of 100ml NS IV and tab ranitidine 150 mg, 30 mins before surgery. Intraoperatively, combined spinal-epidural anaesthesia was administered taking all theaseptic precautions. Visual analogue scale (VAS) was recorded immediately on shifting to a postoperative room, and then at 1, 4, 8, 12, and 24 hr for both groups. Epidural boluses (10 ml of 0.125% bupivacaine with 2 μg/ml of fentanyl) were given whenever the patient's visual analogue scale was more than 4. The time at which the first epidural bolus was required by the patient was recorded. The total number of epidural boluses given over 24 hours based on VAS was recorded for both, the preemptive and placebo groups. If the patient still complained of pain, IV diclofenac 75 mg was given if the VAS was more than 4, while IV diclofenac 75 mg along with IV tramadol 50 mg was given if the VAS was more than 6. Patient satisfaction with anesthesia care, in general, was assessed 24 hrs postoperatively. Results A total of 48 subjects were included in the study. During the immediate-postoperative period, and at 8, 12 and 24 hr, the median VASwas significantly low in group A as compared to group B. A significant increase in the demand for epidural bolusimmediate-postoperatively was observed in group B (70.83%) compared to group A (4.17%) (p-value of <0.001).At 8 hr, 12hr, and 24hr, patients in group A found a significantly less need for epidural boluses compared to Group B. The mean total number of epidural boluses taken in group A was significantly less compared to group B (1.79 ± 0.41 VS 3.33 ± 0.48, p-Value <0.001). In group A, all patients reported no requirement for diclofenac and tramadol. In group B, 8.33% required diclofenac 75 mg, while the remaining 91.66% had no requirement for diclofenac and tramadol. The difference in patient satisfaction with anaesthesia care in general between the two study groups was found to be significant with a p-value of 0.027. Patients in Group A were very satisfied compared with those in group B. Conclusions The study found that the pre-emptive multimodal analgesia group had better postoperative pain control because they required fewer epidural boluses and no extra analgesics postoperatively. This group was more satisfied with the anaesthesia care in general.

MP26-04 24-HOUR URINE COLLECTIONS PERFORMED IN THE IMMEDIATE POST-OPERATIVE PERIOD ARE ACCURATE FOR METABOLIC STONE EVALUATION

You have accessJournal of UrologyCME1 May 2022MP26-04 24-HOUR URINE COLLECTIONS PERFORMED IN THE IMMEDIATE POST-OPERATIVE PERIOD ARE ACCURATE FOR METABOLIC STONE EVALUATION Emily Serrell, Margaret Knoedler, Shuang Li, Sean Hedican, Sara Best, Kristina Penniston, and Stephen Nakada Emily SerrellEmily Serrell More articles by this author , Margaret KnoedlerMargaret Knoedler More articles by this author , Shuang LiShuang Li More articles by this author , Sean HedicanSean Hedican More articles by this author , Sara BestSara Best More articles by this author , Kristina PennistonKristina Penniston More articles by this author , and Stephen NakadaStephen Nakada More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002569.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Many experts advocate collecting an initial 24-hour (24h) urine study at least one month after stone surgery. We believe performing 24h urines earlier improves compliance without compromising results. We hypothesize that in the absence of medical or metabolic intervention, 24h urine studies collected within a month of stone treatment will not differ significantly from those collected later. METHODS: An IRB approved retrospective database of adult patients who underwent surgical treatment for urolithiasis (1/1/2009-8/31/2021) was analyzed. Information was collected for those with a first 24h urine study within a month of surgery and a second within 24 months of the first. Patients were divided into four groups based on treatment between collections: no new treatment; seen in metabolic stone clinic without new medication; seen in metabolic stone clinic with new medication; not seen in metabolic stone clinic but with new medication prescribed by a urologist. Direct differences between two urine studies were compared by multivariate analysis. 24h urine analytes included: calcium, oxalate, uric acid, citrate, pH, volume, sodium, phosphate, magnesium, potassium, creatinine, and sulfate. RESULTS: Of 172 patients with 24h urine studies within a month of surgery, a second study was collected an average of 8.4±4 months later. In 26 patients with no new treatment between first and second study, there were no significant differences in urine analytes (Figure 1A). The 46 patients seen at metabolic stone clinic with new medication had increased urine pH (6±0.7 vs 6.2 ±0.7, p=0.01) and potassium (54±24.4 vs 62.5±28.4, p=0.02). The 89 patients seen at metabolic stone clinic with no new medication had increased volume (2.1±0.8 vs 2.4±0.9, 0.004). The 12 patients with new medication prescribed by urologist had increased potassium (48.9±17.4 vs 65.7±16.8, 0.016) and volume (1.9±0.6 vs 2.5± 0.9, p=0.014; Figure 1B). CONCLUSIONS: Twenty-four hour urine studies performed within a month of stone surgery did not differ significantly from studies collected later. Our report suggests that collections performed in the immediate post-operative period are valid, which should improve compliance in metabolic evaluation. Source of Funding: na © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e439 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Emily Serrell More articles by this author Margaret Knoedler More articles by this author Shuang Li More articles by this author Sean Hedican More articles by this author Sara Best More articles by this author Kristina Penniston More articles by this author Stephen Nakada More articles by this author Expand All Advertisement PDF DownloadLoading ...

Pilot study of the effect of therapeutic photobiomodulation on postoperative pain in knee arthroplasty

Nine participants undergoing primary TKA submitted to spinal anesthesia, sedation, ultrasound-guided obturator and Femoral nerve Block analgesia, and photobiomodulation Therapy (FBMT) were evaluated regarding postoperative pain and morphine consumption. FBMT sessions were performed in the Immediate Postoperative period (IPO) and after 24 hours. Participants received 16.7±15 mg of morphine up to the third postoperative day. At IPO, mean pain score was 4.8±3.2 and 5.6±3.5, at rest and on movement, respectively. Photo biomodulation therapy can be considered an option for mitigating pain for patients undergoing TKA.

Respiratory mechanics behavior after heart surgery: an experimental study

Changes in ventilatory mechanics and their consequent pulmonary complications are common after surgical procedures, particularly in cardiac surgery (CS), and may be associated with both preoperative history and surgical circumstances. This study aims to compare ventilatory mechanics in the moments before and after cardiac surgery (CS), describing how pulmonary complications occurred. An experimental, uncontrolled study was conducted, of the before-and-after type, and with a descriptive and analytical character. It was carried out in a private hospital in the city of Salvador, Bahia, Brazil, and involved 30 adult patients subjected to CS. In addition to clinical and epidemiological variables, minute volume (VE), respiratory rate (RR), tidal volume (VT), forced vital capacity (FVC), maximum inspiratory pressure (MIP), and peak expiratory flow (PEF) were also recorded. Data were collected in the following moments: preoperative (PRE-OP) period, immediate postoperative (IPO) period, and 1st postoperative day (1st POD). The sample was aged 48.1 ± 11.8 years old and had a body mass index of 25.5 ± 4.9 kg m-2; 60% of the patients remained on mechanical ventilation for less than 24 hours (17.5 [8.7-22.9] hours). There was a significant reduction in VT, FVC, MIP and PEF when PRE-OP versus IPO, and PRE-OP versus 1st POD were compared (p &lt; 0.05). There were no significant changes between IPO and the 1st POD. The highest incidence of pulmonary complications involved pleural effusion (50% of the patients). This study showed that patients subjected to CS present significant damage to ventilatory parameters after the surgery, especially in the IPO period and on the 1st POD. It is possible that the extension of this ventilatory impairment has led to the onset of postoperative pulmonary complications.

Morbidity and clinicoradiological outcomes of anterior lumbar arthrodesis using tantalum intervertebral implants

PurposeThe objective of this study was to assess the morbidity of Anterior Lumbar Interbody Fusion (ALIF) using an intervertebral tantalum implant. Tantulum is an extremely porous metallic material which possesses properties of osseointegration, osteoinduction and osteoconduction while offering superior primary stability, compared to other materials more commonly used (polyether ether ketone or PEEK, titanium). Perioperative morbidity, short-term functional outcomes (2 years) and radiographic impaction of implants were also analysed. MethodsThis retrospective monocentric study involved 94 patients operated on between 2014 and 2017 for degenerative disc disease (75%), degenerative spondylolisthesis (3%) or isthmic lytic spondylolisthesis (22%). Sixty-five patients (69%) had isolated (“stand-alone”) ALIF procedures, 24 (26%) with associated anterior osteosynthesis and 5 (5%) with associated posterior osteosynthesis. A Kaplan-Meier survival curve was established with surgical revision listed as the main criterion for failure. Perioperative complications were identified. The clinical evaluation at the last follow-up used a Visual Analogue Scale for radicular pain (VAS-R), for lumbar pain (VAS-L) and the Oswestry Disability Index (ODI) score. The impactions, assessed on x-rays, were divided into 2 groups according to severity in order to establish risk factors (RF). ResultsThe primary objective showed a 2-year survival rate of 94% (95% CI [0.88; 0.99]). Two patients had early surgical revision for impaction and 4 patients had late surgical revision for pseudarthrosis. The rate of perioperative complications was 8.5%, mostly due to vascular causes. At the average follow-up of 33 months (24–59), the clinical results were significantly improved and the impaction rate was 36% in the immediate postoperative period (IPO) and 47% at one year. ConclusionALIF using an intervertebral tantalum implant is a reliable, reproducible and low morbidity technique. However, it is accompanied by a significant rate of immediate and secondary impaction but without any resounding influence on short-term clinical outcomes. Level of evidenceIV.

Use of Mentholated Popsicle in the Management of the Elderly Patient's Thirst in the Immediate Postoperative Period: A Randomized Controlled Trial

PurposeThis study aimed to compare a mentholated popsicle with usual care (absolute fasting) in the change in thirst intensity and discomfort in elderly patients in the immediate postoperative period (IPP). DesignA randomized controlled trial. MethodsThe sample consisted of 50 elderly patients (60 years or older) in the IPP who were randomly assigned to two groups: experimental group (20 mL mentholated popsicle) and control group (usual care). The outcomes, thirst intensity and discomfort, were assessed at baseline and 20 minutes after the intervention. FindingsThe mentholated popsicle presented a statistically significant (P < .001) decrease in thirst intensity and discomfort by 5.0 in the median and a Cohen's r large effect size for both outcomes. There were no adverse events or side effects. ConclusionsThe use of a mentholated popsicle decreased the intensity and discomfort of the elderly patient's thirst in the IPP.

Hipotermia no pós-operatório imediato: percepção de técnicos de enfermagem

Objetivo: Conhecer a percepção de técnicos de enfermagem que atuam na sala de recuperação pós-anestésica (SRPA) de um hospital filantrópicode grande porte de Porto Alegre sobre hipotermia no pós-operatório imediato (POI). Método: Estudo de campo, exploratório, descritivo e qualitativo.A coleta de dados foi realizada no período de abril a maio de 2017, por meio de entrevista gravada em áudio, utilizando um roteiro composto de10 questões. Utilizou-se a análise temática para tratamento dos dados. Resultados: Participaram do estudo 19 técnicos de enfermagem. A análise dosdados possibilitou elencar quatro categorias: percepção sobre a definição de hipotermia; complicações da hipotermia para o paciente no POI; condutas deprevenção e reversão de hipotermia; vivências relacionadas a situações de hipotermia. Conclusão: Os entrevistados demonstraram conhecimento sobreos cuidados de enfermagem para prevenção e reversão da hipotermia em pacientes no POI que se encontram na SRPA.

Evaluation of transversus abdominis plane block for renal transplant recipients - A meta-analysis and trial sequential analysis of published studies.

Background:Patients undergoing renal transplant (RT) have altered drug/opioid pharmacokinetics. Transversus abdominis plane (TAP) block in renal transplant recipients has been recently evaluated for analgesic and opioid-sparing potential by many trials.Methodology:The studies comparing TAP-block to conventional analgesic regimens for RT were searched. Comparisons were made for total opioids consumed (as morphine-equivalents) during the first postoperative 24-h (primary objective), intraoperative, and immediate-postoperative period. Pain scores and postoperative nausea-vomiting (PONV) were also evaluated. Trial sequential analysis (TSA) was used to quantify the strength of analysis.Results:Ten-trials with 258 and 237 patients in control and TAP-block group, respectively, were included. TAP-block decreased the 24-h (reported in 9-trials) opioid consumption by 14.61 ± 4.34 mg (reduction by 42.7%, random-effects, P < 0.001, I2 = 97.82%). Sample size of the present analysis (472) was well past the required “information-size” variable (396) as per the TSA for a power of 85%. Intraoperative opioid consumption also decreased by 2.06 ± 0.63 mg (reduction of 27.8%) (random effects, P < 0.001, I2 = 98.84%). Pain scores with TAP-block were significantly lower in both early and delayed postoperative phase. Odds ratio for PONV without TAP block was 1.99 ± 1.05 (Fixed-effects, P = 0.04, I2 = 0%). Publication bias was likely (Egger's test, X-intercept=7.89, P < 0.05).Conclusions:TAP-block significantly lowers the intraoperative and cumulative postoperative 24-h opioid consumption in RT recipients. Persistent and better pain control is achieved when TAP-Block is used. Benefits of TAP block extend beyond the analgesic actions alone as it also decreases the 24-h incidence of postoperative nausea vomiting as well. The technique of the block needs standardization for RT recipients.

DISPLACED SUPRACONDYLAR HUMERAL FRACTURES;

Objective: To compare outcome of patients with supracondylar fractures of humerus treated by cross k wires and lateralentry k wires in children. Study Design: Randomized controlled trial study. Place and duration of study: January 2012 to December2012 at Department of Orthopedics, Nawaz Sharif Social Security hospital, Lahore. Subjects and Methods: Two hundred patients,meeting the selection criteria were identified. These patients were divided into group A and group B randomly. In group A cross k wirefixation and in group B lateral entry k wire fixation was performed. Loss of reduction was assessed and recorded in the immediatepostoperative period and three weeks later at the time of removal of k wires. Range of motion of the elbow, in the form of excellent outcomewas assessed at the end of 12 weeks postoperatively. Results: A total of 200 patients were included in the study. Loss of reduction wasfound in thirty patients (30%) in group A and in forty one patients (41%) in group B. In group A, seventy two patients (72%) had excellentoutcome while twenty eight patients (28%) did not gain the desired range of motion at elbow. In group B, sixty five patients (65%) hadexcellent outcome while in thirty five patients (35%), the desired range of motion at elbow was not achieved. No neurological injuryoccurred with both configurations. Conclusions: Lateral entry k wire fixation is as effective as cross k wire in the treatment of displacedsupracondyler fracture of humerus in children.

Prolonged-release Oxycodone/Naloxone in Postoperative Pain Management: From a Randomized Clinical Trial to Usual Clinical Practice

These studies evaluated the feasibility of using oral prolonged-release oxycodone/naloxone (OXN PR) for the management of acute postoperative pain. Three studies were undertaken: (i) the analgesic efficacy of OXN PR was compared with prolonged-release oxycodone (OXY PR) in patients with knee arthroplasty in an immediate postoperative period (IPOP) study; (ii) OXN PR treatment was compared with other opioids during rehabilitation after knee arthroplasty in a noninterventional study (NIS); and (iii) surgical patients on other opioids were switched to OXN PR postoperatively during a quality improvement programme (QIP). In the IPOP study, the pain intensity at rest score decreased by a similar amount in the OXN PR and OXY PR groups, indicating similar analgesic efficacies. In the NIS, patient assessments indicated enhanced efficacy and tolerability for OXN PR compared with other opioids. The QIP indicated significant improvements in bowel function and less difficulty passing urine at the end of OXN PR treatment compared with baseline. No safety concerns were raised. The analgesic efficacies of OXN PR and OXY PR were similar in postoperative pain settings. OXN PR reduced the degree of restriction in relation to patients carrying out physiotherapy compared with other opioids, and improved bowel and bladder function.

Avaliação de estratégias no manejo da sede na sala de recuperação pós-anestésica

OBJETIVO: Avaliar estratégias simples e seguras para mitigar a sede no pós-operatório imediato (POI). MÉTODOS: Estudo quantitativo, experimental, de corte transversal, com amostra de 90 pacientes. Aqueles que apresentaram sede foram divididos aleatoriamente em dois grupos, Água ou Gelo. RESULTADOS: 96 (75%) relataram sede. O jejum pré-operatório variou de 8 a 37 horas e não houve associação entre o tipo de anestesia, sangramento, tempo de jejum e sede. A intensidade média inicial de sede foi de 5,1 para o grupo Água e 6,1, ao grupo Gelo. Os métodos experimentados mostraram-se eficazes em aliviar a sede no POI. O grupo Gelo teve intensidade final de 1,51 contra os 2,33 de grupo Água. Dois (2,2%) pacientes apresentaram vômitos durante a pesquisa. CONCLUSÃO: A sede é um desconforto real e gera grande sofrimento ao paciente. Este estudo indicou estratégias viáveis e seguras no manejo da sede no POI.

Circulação extracorpórea e complicações no período pós-operatório imediato de cirurgias cardíacas

OBJETIVO: Comparar a frequência de complicações apresentadas pelos pacientes, durante o pós-operatório imediato (POI), de cirurgias cardíacas de acordo com o tempo de circulação extra-corpórea (CEC). MÉTODOS: Estudo de natureza quantitativa, descritivo e correlacional com 83 pacientes adultos divididos em dois grupos de acordo com o tempo de CEC. RESULTADOS: Do total de pacientes, 44 (53%) tiveram o tempo de duração da CEC de até 85 minutos e 39 (47 %) tiveram o tempo acima de 85 minutos. As complicações foram comuns para ambos os grupos, sendo as mais frequentes dor e oligúria. No entanto, hemotórax, pneumotórax e infarto agudo do miocárdio ocorreram apenas no grupo com maior tempo de CEC. CONCLUSÃO: A maioria das complicações ocorridas no POI apresentou frequencia semelhante para os pacientes, independente do tempo de CEC.

Índice de mortalidade durante procedimentos anestésicos: estudo retrospectivo (1996-2006)

O objetivo deste estudo é reportar a incidência de óbitos anestésico-cirúrgicos durante um período de 11 anos (1996-2006), no qual não eram realizados exames complementares e/ou laboratoriais previamente ao encaminhamento para anestesia. Dessa forma, realizou-se um estudo retrospectivo, avaliando-se as fichas anestésicas utilizadas durante os procedimentos realizados no Hospital de Clínica Veterinária (HCV) da Universidade do Estado de Santa Catarina (UDESC). Analisaram-se 7.012 procedimentos anestésicos, sendo 5.500 (78,4%) realizados em cães e 1.512 (21,6%) em gatos, submetidos à anestesia geral. Os óbitos considerados foram os ocorridos durante os períodos trans-anestésico e o pós-operatório imediato, não sendo levada em consideração a classificação da American Society of Anesthesiologists (ASA), a idade dos pacientes, o sexo ou procedimento cirúrgico realizado. Todos os animais foram submetidos aos procedimentos anestésico-cirúrgicos somente com avaliação clínica pré-anestésica, sem exames complementares prévios, e foram monitorados no período trans-anestésico, tomando-se como base a anestesia clínica. Nesse período, observaram-se 63 óbitos decorrentes da anestesia, sendo 49 em cães (77,8%) e 14 em gatos (22,2%). O índice de mortalidade observado em cães foi de 0,89% e, em gatos, de 0,92%. O protocolo anestésico com maior índice de mortalidade em cães foi a associação atropina, xilazina, tiopental e halotano (20,4%), não havendo um protocolo de destaque em relação a esse índice nos gatos. Os fármacos associados com maior taxa de mortalidade foram diazepam, etomidato e isofluorano, tanto para cães, quanto para gatos, quando analisados individualmente.

Elaboração e aplicação de um instrumento de avaliação no pós-operatório imediato com base no protocolo do Advanced Trauma Life Suport

OBJETIVO: Elaborar e aplicar um instrumento de avaliação do paciente no pós-operatório imediato (POI) de anestesia geral baseado no protocolo do Advanced Trauma Life Suport. MÉTODOS: Foi criado um instrumento baseado no ABCDE do Trauma e aplicado na Sala de Recuperação Pós-Anestésica em todos os pacientes adultos submetidos a cirurgias sob efeito de anestesia geral no período de setembro a novembro de 2007. RESULTADOS: Observou-se que 93,5% dos pacientes tinham vias aéreas pérvias, porém 92,2% necessitaram de oxigênio suplementar. Houve alteração na ausculta pulmonar de 15,6% dos pacientes, hipotensão em 16,9% e hipotermia em 23,4%. Observou-se também uma diferença estatisticamente significativa sugerindo que as mulheres apresentam melhores condições de recuperação que os homens. CONCLUSÃO: O exame físico na seqüência proposta pelo ABCDE do Trauma permitiu identificar as principais alterações fisiológicas no POI contribuindo para a assistência de enfermagem.

A Case of Cataract Surgery without Pupillary Device in the Eye with Iridoschisis

PurposeTo introduce a case of iridoschisis patient who underwent cataract surgery successfully without pupil device.MethodsA 64-year-old female who showed iridoschisis of her both eyes underwent cataract operation at her right eye without a pupillary device. The preoperative and postoperative ophthalmologic examinations including visual acuity, intraocular pressure, reaction of anterior chamber, and degree of damage on iris was evaluated respectively.ResultsCataract surgery was performed under topical anesthesia through a clear corneal incision. Iris fibrils were held in place by ophthalmic viscosurgical device (OVD, sodium hyaluronate 3%-sodium chondroitin sulfate 4%, Viscoat®) that was injected into the anterior chamber. A small capsulorrhexis was made and the nucleus was delivered with low-power phacoemulsification, most of which was performed under the anterior capsule. The iris came into contact with the OVDs only and received no mechanical trauma. There were no intraoperative complications such as tear of the iris, hyphema, loss of mydriasis, or rupture of the posterior lens capsule. The edema of corneal stroma and inflammation of anterior chamber was shown at immediate-postoperative period, but completely subsided 2 weeks later. The visual acuity showed improvement from 20/400 to 20/30.ConclusionsIn iridoschisis patients, there is a risk of aspiration of iris fibers during cataract surgery. With adequate use of OVD and careful modulation of surgical devices, cataract surgery was successfully performed without using extra pupil-supporting device.

Prevention of Intracardiac/Pulmonary Thrombosis During Liver Transplantation

inserted the day prior to surgery:using bupivacaine, fentanyl, andadrenalin) or patient-controlled IVmorphine analgesia during the im-mediate postoperative period. Peri-operative care was standardized(all patients underwent general an-esthesia and received a mediansternotomy). When the two groupswere compared, the only differencewas a shorter time to postoperativetracheal extubation in patients re-ceiving thoracic epidural analgesia(2.3 vs 7.3 h). Absolutely no dif-ferences were observed regardingpostoperative analgesia (at rest andduring cough), degree of sedation,lung volumes (forced vital capacity,forced vital capacity at one second,peak expiratory flow), degree of am-bulation, global quality of recoveryscore (including all five domains),cardiac morbidity, renal morbidity,neurologic outcome, intensive careunit stay, or hospital length of stay.As reports describing seriouscomplications or lack of clinicalbenefits increase, the question mustbe asked: Is it time to abandonthoracic epidural techniques in pa-tients undergoing cardiac surgery?

Pseudoaneurysm of Dorsalis pedis artery due to inversion injury of the ankle

A 22-year-old University student injured his rightankle while playing soccer. He presented with grossswelling,painaroundtheankleandnumbnessofthetoes. X-ray of the foot revealed soft tissue swellingwith no bony injury. He was initially managed withbed rest, foot end elevation, local ice packs andanti-inflammatory agents. Though most symptomssettled, the numbness in the toes persisted.Duplex Ultrasound of the ankle to grade theseverity of injury, identified a pseudoaneurysm ofthe dorsalis pedis Artery (Fig. 1). It measured3cm 5 cm and had a wide neck of 0.6 cm. Com-pression treatment was not attempted due to pain.The aneurysm was surgically explored. The dor-salis pedis artery was exposed and controlled. Sur-rounding haematoma was evacuated and the rent inthe artery identified (Fig. 2). As it involved morethan two-third the circumference of the artery, itwas transacted and an end-to-end anastomosisdone. A posterior slab was applied to immobilisethe ankle.The patient had an uneventful recovery. Heregained sensation to his toes. Ankle swellingsettled. A good pulse was felt clinically. Duplex scanconfirmed the artery to be patent during immediatepost-operative period and at 6-week follow-up.

Uso do óxido nítrico inalatório no tratamento da crise hipertensiva pulmonar no pós-operatório de transplante cardíaco

OBJETIVO: Este trabalho relata a experiência no manuseio da crise hipertensiva pulmonar (CHP) refratária, com o uso do óxido nítrico inalatório (NOi) no pós-operatório imediato do transplante cardíaco (TC) ortotópico. MÉTODOS: De outubro/1997 a fevereiro/2002 foram realizados 31 TC em adultos, sendo incluídos pacientes com RVP < 6uW, ou < 2,5uW na prova farmacológica. Após o período de circulação extracorpórea (CEC) (M=101±21 minutos), todos fizeram uso de dobutamina, dopamina e milrinona; entretanto, frente à ausência de resposta adequada e CHP, administrou-se NOi em doses crescentes de 20 a 40ppm. Foram utilizados registros das pressões através de cateter no átrio esquerdo e no tronco da artéria pulmonar, gasometria arterial seriada e ecocardiograma transtorácico (ETT). O tempo médio de morte encefálica (ME) do doador foi de 16<FONT FACE=Symbol>±5,1</FONT>horas<FONT FACE=Symbol>.</FONT>RESULTADOS: Cinco pacientes (1 mulher), com idade média de 42 anos, fizeram uso de NOi por apresentarem critérios de CHP, todos com sinais de baixo débito cardíaco. O tempo médio de CEC foi de 150,8±34,3 minutos, a média sistólica arterial pulmonar foi de 87mmHg (75-115) e a PO2 média de 60mmHg (FiO2 100%), sendo evidenciada dilatação moderada a severa do ventrículo direito no ETT. Foi administrado NOi durante uma média 35h (6-96), iniciando-se desmame após estabilização hemodinâmica. O tempo médio de ME do doador foi de 27,6±5,5horas, a internação hospitalar média foi de 63 dias (17-145), uma morte ocorreu por sepse no 17º PO e os demais pacientes estão em CF I (NYHA). CONCLUSÕES: O tempo de CEC superior a 120 minutos e tempo de ME do doador superior a 20 horas sugerem fatores de risco para CHP no período pós-operatório imediato do TC. O NOi é uma ferramenta útil no manuseio desta complicação, refratária ao tratamento convencional no POI de pacientes submetidos ao TC.

PULMONARY FUNCTION IN THE IMMEDIATE POSTOPERATIVE PERIOD: Observations of Vital Capacity, Timed Vital Capacity, and Maximum Expiratory Flow Rates in Two Groups of Thoracotomy Patients and a Group of Nonthoracotomy Patients for Seven Postoperative Days

PULMONARY FUNCTION IN THE IMMEDIATE POSTOPERATIVE PERIOD: Observations of Vital Capacity, Timed Vital Capacity, and Maximum Expiratory Flow Rates in Two Groups of Thoracotomy Patients and a Group of Nonthoracotomy Patients for Seven Postoperative Days