Warm Normal Saline Research Articles

Pain assessment during outpatient hysteroscopy using room temperature versus warm normal saline solution as a distention medium – a prospective randomized study

To assess the efficacy of warm normal saline distention solution versus a standard, room-temperature normal saline as distention medium for pain relief during outpatient hysteroscopy. A prospective randomized case-placebo controlled study was conducted in tertiary care centre - Central Clinical Hospital of Ministry of Interior and Administration. Study group consisted of 100 women referred for outpatient hysteroscopy between January 2015 and July 2015. Every patient, who was referred for an office hysteroscopy, was offered to participate in the study to receive a sterile, 0.9% normal saline warmed up to 36⁰C as distention medium. Control group were women receiving sterile, room temperature of 25⁰C, 0.9% normal saline solution as a distention medium. No pre-medication nor analgesia were used. A visual analogue scale (VAS) was used for one-dimensional pain assessment. Women were asked to mark a VAS score before, during, and five and 15 minutes following the procedure. Median VAS scores during and directly after the anaesthesia-free hysteroscopy were no different between two groups. (p = 0.554 and p = 0.121, respectively). There were also no differences in the procedure time between groups (p = 0.845). Warm normal saline distention solution does not reduce the pain during and at the end of the outpatient hysteroscopy. The effect does not depend on the age of women, menopausal status, parity or type of outpatient hysteroscopy (operative or diagnostic).

Anatomical Investigation of the Portal Vein in the Rabbit (Oryctolagus cuniculus)

ABSTRACT Background and Aim: This study was carried out to investigate the course and distribution of the portal vein that mainly drained the gastrointestinal tract. Anatomical studies on the venous drainage of the gastrointestinal tract of the rabbit were necessary to know the pattern of its blood supply to gain information in benefit of experimental surgery, pharmacology and toxicology which can be applied to domestic animals and human, also helped in the field of veterinary comparative anatomy. Material and Methods: The present work was carried out on six adult, apparently healthy rabbits of both sexes. The animals were slaughtered, cannulated and flushed with warm normal saline (0.9%). Then animals were injected with blue gum milk latex, the specimens were subjected to fine dissection. Results: The main tributaries of the portal vein were; the gastroduodenal, Splenic, left gastric, caudal pancreaticoduodenal and cranial pancreaticoduodenal vien. Conclusion: This results show a variation between rabbits and other mammals, which helped in the field of comparative anatomy. Key words: Rabbits; Venous drainage; Portal vein; gastrointestinal tract.

Efficacy of Lidocaine Patch in Relieving Severe Sickle Cell Leg Ulcer Pain

Introduction: Currently, there is a plethora of analgesics on the market that vary in type, method of application, duration of action, side effects and price. Thus we have, among other things, NSAIDs, opioids, anesthetics, cannabinoids, gases and venom-derived pain relievers. Formulations include short-acting, long-acting, extended release or controlled release. Administration of analgesia could be oral, topical, parenteral, intrathecal, epidural, rectal, intranasal, epidermal, submucosal, sublingual, etc. Despite the abundance of these drugs in the western world, there is an embarrassing dearth in developing countries. Thus the challenge to find the right analgesic for a specific patient with a specific etiology of pain is often overwhelming. It is within this framework of this complexity that we describe the efficacy of the lidocaine patch in a patient with a severely painful leg ulcer refractory to standard methods of therapy in a patient with sickle cell anemia (SS)Patient & Methods: The patient is a 35 year-old African Brazilian man, known to have SS presented at the Instituto de Hematologia Arthur de Siqueira Cavalcanti (HEMORIO) in Rio de Janeiro, Brazil with a severely painful leg ulcer over the lateral left malleolus of 11 years duration. Dimensions of the ulcer were: 10 cm long and 6 cm wide and covered with purulent exudate. The pain was constant and stabbing in nature with an intensity score of 10 over 10 on presentation. The pain was partially responsive to oral tramadol and he refused to take opioids. Given the large size of the ulcer and purulent exudate, application of topical opioids was not considered an appropriate option due a potentially barrier effect of the exudate. Accordingly decision was made to treat the pain with lidocaine patch applied peripherally around the ulcer. Direct application of the patch would stick to the ulcer bed thus limiting its analgesic effect and previous studies showed high blood flow in the immediate peri-ulcer area compared to distant unaffected skin. The lidocaine patch was applied daily as follows: The ulcer was first cleaned with warm normal saline and polihexamide, collagenase was applied to the ulcer bed and the lidocaine patch was applied on the skin on the periphery of the ulcer. The lidocaine patch had to be cut to fit the periphery of the ulcer. The patient was instructed to remove the patch 12 hours after its application. He was taught how to remove and reapply the bandage around the ulcer. Moreover, the patient was instructed to keep a written diary of the intensity of the leg ulcer pain one, six and 12 hours after the application of the patch.Results: On the first day of treatment the intensity of the ulcer pain was 10 over 10 and he did not allow the nurse to apply the bandage because that made the pain much worse. One hour after the application of the lidocaine patch the pain score dropped to 3 over 10 and at 6 and 12 hours post application the pain score was zero. On the next day he presented to the wound center with a pain score of 4 over 10 and this time he allowed the nurse to remove and apply the bandage without complaints. After the daily application of the lidocaine patch he did not require oral tramadol to treat the ulcer pain.Conclusion: The lidocaine patch seems to be an effective and save method to treat the pain of sickle cell leg ulcers. Moreover, it obviates the need of oral analgesics to treat the pain. Recent studies suggest that nonneuronal tissues, such as skin keratinocytes in particular, express several isoforms of Na+ channels and of the TRPV family of receptors. These findings suggest that skin may play an important role in the pathophysiology of pain. Thus the application of lidocaine to the periphery of the ulcer inhibits the transmission of painful stimuli directly in situ. A potential problem is that the patch is expensive. DisclosuresNo relevant conflicts of interest to declare.

Pre-partum Cervico-Vaginal Prolapse in a Crossbred Cow and Its Therapeutic Management-A Case Report

A 4 years old crossbred cow was reported to have protusion of uterus in Pyllum Village, Ri-Bhoi District Meghalaya. India. The cow was restrained in standing position and epidural anaesthesia (2% Lignocaine hydrochloride @0.2 mg/kg body weight) was administered. The prolapsed organ was made aseptic by washing with 2% potassium permanganate solution followed by washing with warm normal saline. A course of parenteral antibiotic (Ceftriaxone sodium @5mg/kg) along with anti-inflammatory drug (Meloxicam @1ml/kg body weight) was given for 5days. To maintain the full term pregnancy progesterone (hydroxyprogesterone @3ml/animal) was injected intramuscularly. The cow recovered successfully and delivered a healthy calf after complete term of gestation.

Gross Anatomical Studies on the Celiac Artery in The Domestic Fowl (Gallus gallus domesticus)

The present study was carried out on eight adult, apparently healthy chickens of both sexes. The birds were slaughtered and the descending aorta was cannulated and flushed with warm normal saline (0.9%). Then birds were injected with colored gum milk latex. The origin, course and distribution of the celiac artery were studied. The celiac artery originated from the descending aorta in the level with the 5 th rib. It proceeded ventrally and slight cranial were it gave off the esophageal artery after few mm from its origin, the dorsal proventricular artery just before its bifurcation into right and left branches at the cranial end of the spleen.

Gross Anatomical Studies on the Celiac Artery in Cattle Egret (Bubulcus ibis) with Special Reference to the Arterial Supply of the Stomach

The present study was carried out on ten adult, apparently healthy cat- tle egrets of different ages and sex- es. Each bird was exsanguinated and the descending aorta was cannulated and flushed with warm normal saline solution (0.9%), then injected with red colored gum milk latex. The origin, course and distribution of the celiac artery were described. The celiac artery erupted from the right face of the descending aorta opposite to the 4th or 5thvertebral rib, on a level with the junction of the esophagus and the proventriculus. It gave off the Aa. esophageales, A. proventricularis dorsalis, Aa. lienales, and A. hepatica, then bifurcated into left and right branches. The left branch of the celiac artery gave off A. proventricularis ventralis and A.gastrica ventralis then continued as the A.gastrica sinistra. The right branch of the celiac artery released the Aa. Ileocecales, Rr. succi, A. gastroduodenalis, A. gastrica dextra then continued as A. pancreaticoduodenalis.

Laparoscopic stripping ovarian cystectomy in children without use of electrocautery in residual ovarian bed: experience in Chittagong, Bangladesh

Objective: Laparoscopic excision has now become the standard treatment option for benign ovarian cysts. Stripping is an effective and popular technique practiced by the surgeons for ovarian cyst excision. Use of electro-cautery in the residual ovarian bed is blamed for the reduction of ovarian reserve. Our experience of laparoscopic stripping technique without use of electro-cautery in the remaining ovarian tissue is described. Materials and Methods: From 1 January 2006 to 31 December 2010, 26 cases were considered for laparoscopic stripping ovarian cystectomy. Using mono-polar hook cautery a flap was marked and raised on cyst wall and serous fluid sucked out. A plane was then created between inner and outer linings of the cyst wall, and inner lining peeled off. Warm normal saline wash was then given and the stripped lining was brought out through supra-umbilical port. Patients were followed up at 15 days, 1 month, 3 months, 1 year and then yearly with ultrasonogram at 3 months and 1 year. Patient’s age, operative time and outcome, blood loss and complications were studied retrospectively. Results: Age ranged from 3.5 to 16 years. Presenting complaints included: abdominal pain (11), abdominal swelling (8) and palpable abdominal lump (7). Average operative time was 40.30 minutes and operative blood loss ranged from 10 to 36 ml. There was no intra or post-operative complication. There was no recurrence of cyst confirmed by ultrasonography at 3 months and 1 year. Conclusions: Avoiding use of electro-cautery during ovarian cystectomy by stripping technique can prevent damage and reduction in ovarian reserve. DOI: http://dx.doi.org/10.11593/bje.2013.0101.0007 Bangladesh Journal of Endosurgery Vol.1(1) January 2013: 26-28

Tracheal occlusion conditioning causes stress, anxiety and neural state changes in conscious rats

Evidence from human and animal studies indicates that mechanical loads to breathing are stressful stimuli and evoke compensatory behaviours. Conditioning of stressful stimuli is known to cause changes in basal stress levels and behaviour. Individuals with respiratory obstructive diseases repeatedly experience bouts of airway obstruction, which may act as a form of conditioning, and often have affective disorders, such as anxiety and depression. It is unknown whether the development of affective disorders in these individuals results from the unexpected recurring respiratory perturbations. To investigate this possibility, we developed a model to elicit tracheal occlusion (TO) in conscious rats and exposed them to 10 days of TO conditioning. We hypothesized that healthy, conscious animals exposed to TO conditioning would develop stress and anxiety and would have modulated neural activity in respiratory, stress, discriminative and affective neural regions. Following TO conditioning, rats had increased basal corticosterone levels, greater adrenal weights and elevated anxiety levels compared with animals not receiving TO. Significant increases in cytochrome oxidase staining were found in brainstem respiratory nuclei, periaqueductal grey, dorsal raphe, thalamus and insular cortex. These results suggest that healthy animals develop stress and anxiety responses to respiratory load conditioning via inescapable tracheal occlusions, which may be mediated through state changes in specific brain nuclei.

Effect of cysteamine and epidermal growth factor (EGF) supplementation in maturation medium on in vitro maturation, fertilization and culturing of embryos in sheep

The present study was conducted to investigate the effect of the exogenous addition of cysteamine (200μM/ml) and epidermal growth factor (EGF; 20ng/ml) to the maturation medium on maturation, fertilization and subsequent development of sheep oocytes, in vitro. The ovaries (n=113) of slaughtered ewes were collected from local abattoirs in a warm normal saline solution, containing Gentamicin sulfate (50μg/ml) in a thermos flask. The acceptable and fair quality oocytes obtained by the puncture aspiration technique were subjected to maturation in three different media viz.; for 24h under 5% CO2 and humidified atmosphere at 38.5°C. The matured oocytes were then subsequently subjected to fertilization using cauda epididymis spermatozoa from slaughtered rams and cultured for 6 days. The maturation percentage recorded in the EGF supplemented medium (84.9%) was significantly higher than in the cysteamine supplemented (69.6%) and control medium (67.2%). The fertilization and cleavage rates recorded were 73.7%, 49.5%, 72.3%, 52.7% and 76.5%, 55.5% in control, cysteamine and EGF supplemented media respectively. These differences were non-significant (p>0.05). The morula formation rate recorded in the EGF supplemented (38.7%) and cysteamine supplemented (36.7%) media was significantly (p<0.05) higher, than in the control (22.1%) medium. In conclusion, the results indicate that EGF plays an important role in the in vitro maturation and both EGF and cysteamine have a stimulatory effect on further embryonic development in sheep.

Effect of lead acetate injection into pregnant mice on the testis function of their male offspring at puberty

the study aimed to follow up the effects of injection lead acetate into pregnant females on the testicular development and semen quality of their male births at puberty time. Forty mature female Swiss Webster mice (8-10) weeks old were divided into two equal groups (experimental and control). After mating with fertile males, the pregnant females injected intraperitoneally with 0.1 mg/kg of body weight of lead acetate from the first day of gestation and continued throughout the gestation period 20 days. While the control groups were injected by the same dose and rout of injection with normal saline. At parturition, numbers of the neonate were recorded. After six weeks the male births only isolated and weighted then mated with normal fertile females to evaluate their fertility through assessing their birth rate, then sacrificed to get their testes; each testis was weighted and the left one was fixed, then histological sections with a thickness of 5 microns were prepared. The epididymis was minced with warm normal saline to get a spermatozoal suspension to evaluate the sperm concentration, sperm motility, and abnormal sperm morphology and sperm viability. Results showed a highly significant decrease in the body and testicular weights of experimental male animals. A highly significant reduction in their birth rate after mating with normal partners was recorded together with a significant inverse changes in all semen parameters.

The infusion method trial of void vs standard catheter removal in the outpatient setting: a prospective randomized trial

• To ascertain if filling the bladder with warm normal saline before trial of void (TOV) reduces time to decision of outcome of TOV and time to discharge compared with standard in-dwelling catheter (IDC) removal in the outpatient setting. • A prospective randomized controlled trial (not blinded) was carried out in the day procedure unit. Randomization was done using computer-generated random numbers. The sample size was calculated based on initial pilot data using α= 0.05 and β= 0.2 and a clinically important reduction of ≥60 min for time to decision of outcome of TOV (primary outcome measure). • In all, 60 consecutive patients were recruited from two referral sources: presentations of acute urinary retention to the emergency department and patients discharged home after failing TOV postoperatively. • The infusion method group (32 patients) had 300-500 mL warm normal saline infused into the bladder before removing their IDC and the control group (28) had standard IDC removal. • Data were collected and analysed using the two-tailed Mann-Whitney U-test. Statistical significance was set at P < 0.05. • The median time to decision was 135.0 (95% confidence interval CI 95.0-190.0) min in the infusion group and 247.5 (95% CI 189.6-294.1) min in the control group. • Patients undergoing a bladder infusion had a shorter discharge time [180.0 (95% CI 126.0-226.9) min] than patients in the standard-IDC-removal group [262.5 (95% CI 233.8-315.0) min]. • The infusion arm shortened time to decision by 112.5 min (P < 0.001) and time to discharge by 82.5 min (P < 0.001). • Furthermore, patients in the infusion group were 1.56 times more likely to achieve catheter-free state after TOV (risk ratio 1.56, 95% CI 1.03-2.36; P= 0.03). • The infusion method for TOV is safe and expeditious, making it ideal for the outpatient setting. This randomized study shows that the infusion method enables a rapid determination of outcome of TOV with a greater chance of success and shortened discharge times.

Operative management of typhoid ileal perforation in children

Intestinal perforation resulting from complicated typhoid fever still causes high morbidity and mortality. The purpose of the present study is to evaluate the outcome of its surgical management in Nigerian children. Emergency laparotomy and repair of the ileum was performed on 46 children with typhoid ileal perforation at the Federal Medical Centre (FMC), Azare, Nigeria, between January 2004-December 2008. This was followed by copious peritoneal lavage with warm normal saline and mass closure of the abdomen. There were 28 (60.86%) boys and 18 (39.13%) girls, with a mean age of 9.5 +/- 3.22 (range, 15 months-15 years). Abdominal pain (45), fever (44), and abdominal distention (36) were the most common presenting symptoms and majority of the patients (36) perforated within 14 days of illness. Solitary ileal perforations were the most common pathology, found in 31 (67.4%) cases. Simple closure of the perforations after debridement of the edges was the most frequent operative procedure performed. A total of 21 patients had one or more complications which included wound infection (21), postoperative fever (16), and wound dehiscence (6). Postoperative anaemia was a problem in 23 (50%) patients. The mortality rate was (13) 28.3%. The mean duration of hospital stay for survivors was 22.9 +/- 12.3 (range, 6-46 days). This was not significantly affected by the location or number of perforations on the ileum. The clinical course of typhoid ileal perforation may be different for the very young. The typically high rate of complications can be reduced if operation is undertaken earlier. Solitary ileal perforations can be managed safely with simple closure.

An Easy Technique for Laparoscopic Placement of Seprafilm

The use of antiadhesive sheets has greatly reduced the number of postoperative adhesions after abdominal surgery. A major problem is that these sheets are difficult to deliver into the peritoneal cavity because they are not malleable and easily stick when wet. This article describes a simple technique for administering Seprafilm sheets onto the abdominal viscera after laparoscopic surgery. The Seprafilm sheets are dissolved before the end of surgery in warm normal saline and the solution is placed into a Toumey catheter tip syringe. The syringe is then attached to a Robinson catheter, which is introduced into the abdomen via a laparoscopic trocar. Under direct laparoscopic visualization, the Seprafilm solution is squirted into the damaged peritoneal surfaces. Long-term studies are needed to assess whether our Seprafilm solution technique has the same efficacy as the use of whole sheets.

Intraoperative hydrostatic reduction of intussusception

Aims:To find out an easier way of reduction of intussusception during open surgery to avoid unnecessary bowel injury.Materials and Methods:Under general anesthesia, before laparotomy, warm normal saline was infused into the rectum with a Foley catheter and an intravenous drip set maintaining the level of the bottle at 80 cm above the operating table. After opening the abdomen, pressure was applied on the colon filled with normal saline distal to the intussusceptum. The pressure was transmitted to the intussusceptum and the walls of the intussuscipient and caused reduction of intussusception without any injury to the intussuscipient and intussusceptum. This procedure was performed on those patients on whom laparotomy was performed as a primary procedure due to nonavailability of fluoroscopy or ultrasonography.Results:Between August 1998 and July 2005, we had six patients of mean (range) age 11 months (7–17 months). In two cases, at laparotomy, the intussusceptions were found to have already reduced.Conclusions:Gentle finger pressure is necessary for reduction of intussusception. This subjective “gentleness” is dependant on experience of the surgeon and varies from person to person. Focal pressure on the intussuscipient and apex of the intussusceptum by the finger during reduction may be more damaging than the diffusely transmitted hydrostatic pressure even by a less-experienced surgeon. This will avoid the needless resection and anastomosis of the intestine on many occasions.

Improving Intubation Success Using the CTrach Laryngeal Mask Airway™

The CTrach Laryngeal Mask Airway™ (LMA North America, Inc., San Diego, CA) allows for visualization of the glottis before intubation, as well as concurrent patient ventilation.1However, we have found that even after the administration of glycopyrrolate, the use of antifog liquid, or placing the unit in warm water, the view port either fogs or is obscured by either oropharyngeal secretions or the lubricating gel in the endotracheal tube, should the first intubation attempt be unsuccessful. A simple solution to this problem is to use a hemostat or similar device to advance a disposable sponge swab moistened with warm normal saline (e.g. , Item 6075; Sage Products, Inc., Cary, IL) through the CTrach™ to clean the viewing port. We have now used this technique in more than 10 instances, with uniformly excellent results (fig. 1).*Cleveland Clinic, Cleveland, Ohio. maurtum@ccf.org

Management of Oligohydramnios with Antepartum Amnioinfusion, Amniopatch and Cerclage

To evaluate the efficacy and safety of aggressive management of oligohydramnios. Forty women with oligohydramnios (< 30 complete weeks), either because of preterm premature rupture of membranes or with intact membranes, were prospectively enrolled in this study. Eleven women were assigned to the treatment group and 29 to the control group. Transabdominal amnioinfusion was performed with warm Ringer's lactate or normal saline in all 11 patients in the treatment group. In addition, cerclage was performed in patients with ruptured amniotic membranes. Amniopatch was used to salvage a patient with immediate amniorrhea (< 6 hours) after the above procedures. Nine of the 11 patients prolonged their pregnancy for at least 3 weeks (81.8%), while all 29 patients in the control group delivered their babies within 3 weeks of diagnosis of oligohydramnios ( p < 0.05). Signs of maternal infection were noted in two patients in the treatment group (18.2%). The newborns of eight patients in the treatment group survived beyond 1 month (72.7%), whereas this occurred in only six control patients (20.7%; p < 0.05). Aggressive management seemed to provide prolongation of pregnancy compared with no treatment. Amniopatch salvaged the immediate amniorrhea in our patient.

The use of trans-vaginal laparoscopy in ruling out pelvic malignancy: a case report

Trans-vaginal laparoscopy (TVL) was performed in a patient at high risk for ovarian cancer (OC). During a routine check-up vaginal sonography and color Doppler studies revealed neoangiogenesis with low resistance in both sides. The left ovary was slightly enlarged, and the increased blood vessels were seen in the center and in the periphery of the left ovary. The patient was placed in the lithotomy position after sedation, and a veres needle was inserted in the posterior vaginal vault. A trocar followed, and warm normal saline was injected in the pelvis. The needle was removed, and a telescope was introduced, connected to a light source and a monitor. Excellent visualization was achieved, and the average time of TVL was 30 min. Dilated veins in both adnexa and pelvic tissues due to severe obesity were visualized. TVL helped in establishing the diagnosis, saving this patient from an unnecessary laparoscopy or laparotomy.

Emergency Treatment of Life-Threatening Intrathecal Methotrexate Overdose

A male 34-year-old patient with aggressive diffuse malignant lymphoma was hospitalized for treatment. Because of high likelihood of CNS involvement, intrathecal methotrexate (MTX) 15 mg was administered with hydrocortisone 100 mg. Shortly after the intrathecal injection the patient became agitated, and complained of severe low back pain and 2 h later he became confused and developed generalized seizures. At this stage, it was realized that the dose contained 1200 mg of MTX (80-fold overdose). The patient developed ARDS and was comatose; he was intubated and transferred to ICU. The patient was immediately treated with intravenous leucovorin 1200 mg, and 15 mg every 6 h, thereafter, for 72 h. In addition, CSF exchange with warm normal saline was initiated via intrathecal catheter, and a total of 200 ml of CSF were replaced during 48 h. Finally, at the end of the exchange 2 mg of leucovorin with 2 mg of dexamethasone were administered intrathecally. MTX levels in CSF 7 h post-injection were 770 μM, and increased to 1250 μM 2 h later. Thereafter, the levels in CSF declined, and 48 h post-injection were 47 μM. The plasma levels of MTX 7 h post-injection were 10 μM, and declined to 0.7 μM at 68 h. The patient regained consciousness and underwent successful weaning from ventilator after tracheostomy. The highest reported intrathecal dose after which the patient survived was 625 mg. Due to the rarity of reported cases, there are no clear guidelines for treatment of massive intrathecal overdose. There is a controversy regarding the toxicity of intrathecal injection of leucovorin. We propose CSF exchange and intravenous leucovorin as the mainstay of treatment.

Lost child

Lost child

Pulmonary Alveolar Proteinosis: Treatment by Bronchofiberscopic Lobar Lavage

The current mainstay of treatment for pulmonary alveolar proteinosis (PAP) is whole-lung lavage. Therapy with granulocyte-macrophage colony-stimulating factor is a possibility, although its long-term safety has not been determined. An alternative procedure is selected lobar lavage by fiberoptic bronchoscopy (FOB). We report here our experiences with lobar lavage by FOB in treating three patients with PAP. PAP was diagnosed in three patients (two men, one woman) who had dyspnea and hypoxemia after undergoing open-lung biopsy. The patients underwent lobar lavage by FOB under local anesthesia. The bronchoscope was wedged into a lobar bronchus. Approximately 2,000 mL warm normal saline solution was instilled via syringe in 50-mL aliquots through a fiberoptic bronchoscope. After undergoing multiple lobar lavages, two patients showed clinical, physiologic, and radiologic improvement. The third patient, who had more advanced disease, showed improvement only in oxygenation. The major complications were severe cough and hypoxemia during lavage. Our experience suggests that bronchoscopic lobar lavage is simple and safe, and may find application in patients in whom a whole-lung lavage with generalized anesthesia may be hazardous, and in patients with less advanced disease whose proteinaceous substances can be removed with a small volume of lavage fluid.