Peritraumatic Plasma Omega-3 Fatty Acid Concentration Predicts Chronic Pain Severity Following Thermal Burn Injury.

Chronic pain is a significant comorbidity of burn injury affecting up to 60% of survivors. Currently, no treatments are available to prevent chronic pain after burn injury. Accumulating evidence suggests that omega-3 fatty acids (O3FAs) improve symptoms across a range of painful conditions. In this study, we evaluated whether low peritraumatic levels of O3FA predict greater pain severity during the year after burn injury. Burn survivors undergoing skin autograft were recruited from three participating burn centers. Plasma O3FA (n = 77) levels were assessed in the early aftermath of burn injury using liquid chromatography/mass spectrometry, and pain severity was assessed via the 0 to 10 numeric rating scale for 1 year following burn injury. Repeated-measures linear regression analyses were used to evaluate the association between peritraumatic O3FA concentrations and pain severity during the year following burn injury. Peritraumatic O3FA concentration and chronic pain severity were inversely related; lower levels of peritraumatic O3FAs predicted worse pain outcomes (ß = -0.002, P = .020). Future studies are needed to evaluate biological mechanisms mediating this association and to assess the ability of O3FAs to prevent chronic pain following burn injury.

Peritraumatic Vitamin D Levels Predict Chronic Pain Severity and Contribute to Racial Differences in Pain Outcomes Following Major Thermal Burn Injury.

Major thermal burn injuries result in approximately 40,000 hospitalizations in the United States each year. Chronic pain affects up to 60% of burn survivors, and Black Americans have worse chronic pain outcomes than White Americans. Mechanisms of chronic pain pathogenesis after burn injury, and accounting for these racial differences, remain poorly understood. Due to socioeconomic disadvantage and differences in skin absorption, Black Americans have an increased prevalence of Vitamin D deficiency. We hypothesized that peritraumatic Vitamin D levels predict chronic pain outcomes after burn injury and contribute to racial differences in pain outcomes. Among burn survivors (n = 77, 52% White, 48% Black, 77% male), peritraumatic Vitamin D levels were more likely to be deficient in Blacks vs Whites (27/37 [73%] vs 14/40 [35%], P < .001). Peritraumatic Vitamin D levels were inversely associated with chronic post-burn pain outcomes across all burn injury survivors, including those who were and were not Vitamin D deficient, and accounted for approximately one-third of racial differences in post-burn pain outcome. Future studies are needed to evaluate potential mechanisms mediating the effect of Vitamin D on post-burn pain outcomes and the potential efficacy of Vitamin D in improving pain outcomes and reducing racial differences.

Radiographic Comparison of Superior and Inferior Gluteal Vessels in Jackknife versus Prone Position: A Prospective, Self-Controlled Trial.

Mortality after gluteal augmentation with fat transfer techniques is extremely high. Placement of fat subcutaneously versus in the gluteal musculature, or both, is considerably debated. The purpose of this study was to radiographically show the anatomical difference in live subjects in different procedural positions: the flexed or "jackknife" versus prone position. A total of 10 women underwent computed tomographic scanning of the pelvis with venous phase run-off in both the jackknife and prone positions. A computed tomography-specialized radiologist then reviewed images and measured distances from the inferior and superior gluteal veins to the skin and muscle. Three-dimensional imaging and analysis were also performed. Measurements were significantly shorter with respect to distance from skin to muscle, skin to vessel, and vessel to muscle observed from inferior and superior gluteal veins in the jackknife versus the prone position. Three-dimensional modeling showed a significant reduction in the volume and inferior and superior gluteal vein diameters when in the jackknife position. When placed in the jackknife position for gluteal augmentation with fat transfer, extreme caution should be taken with the injecting cannula, as the underlying muscle is only 2 to 3 cm deep. Three-dimensional analysis showed narrowed and reduced volume of gluteal vasculature when in the jackknife position; this is a possible indication of torsion or stretch on the vessel around the pelvic rim that could cause vein avulsion injury from the pressurized fat within the piriform space.

Results of a Multicenter Feasibility Study of an Automated Bedside Glucose Monitoring System in the Burn Intensive Care Setting.

Intensive blood glucose regimens required for tight glycemic control in critically ill burn patients carry risk of hypoglycemia and are ultimately limited by the frequency of which serum glucose measurements can be feasibly monitored. Continuous inline glucose monitoring has the potential to significantly increase the frequency of serum glucose measurement. The objective of this study was to assess the accuracy of a continuous glucose monitor with inline capability (Optiscanner) in the burn intensive care setting. A multicenter, observational study was conducted at two academic burn centers. One hundred and six paired blood samples were collected from 10 patients and measured on the Optiscanner and the Yellow Springs Instrument. Values were plotted on a Clarke Error Grid and mean absolute relative difference calculated. Treatment was guided by existing hospital protocols using separately obtained values. 97.2% of results obtained from Optiscanner were within 25% of corresponding Yellow Springs Instrument values and 100% were within 30%. Mean absolute relative difference was calculated at 9.6%. Our findings suggest that a continuous glucose monitor with inline capability provides accurate blood glucose measurements among critically ill burn patients.

Reduction in Central Line-Associated Bloodstream Infections Correlated With the Introduction of a Novel Silver-Plated Dressing for Central Venous Catheters and Maintained for 6 Years.

OBJECTIVE: To assess a novel silver-plated dressing (SD) for central venous catheters in comparison to chlorhexidine gluconate-impregnated sponge (CHGIS) dressings in preventing central line-associated bloodstream infections (CLABSIs) in adult intensive care unit (ICU) patients. DESIGN: Retrospective cohort study. SETTING: Tampa General Hospital, an academic medical tertiary care center. PATIENTS: All adult ICU patients of an academic medical tertiary care center from January 2009 to December 2010. MEASUREMENTS AND MAIN RESULTS: A total of 3189 patient records were studied from 7 different ICUs during the 2-year period. Patients received either CHGIS dressings (January 2009-December 2009) or SDs (January 2010-December 2010). Primary outcomes measured were CLABSI rates per 1000 catheter days and ICU length of stay. There were 30 696 catheter days with CHGIS dressings and 31 319 catheter days with SDs. There was a statistically significant decrease in the rate of CLABSI per 1000 catheter days in the SD group, from 2.38 to 1.28 ( P = .001), with an absolute risk reduction of 1.1. There was a significantly lower incidence in the rate of CLABSI per 1000 catheter days in the SD group (incidence rate ratio [IRR] = 0.54, 95% confidence interval [CI]: 0.36-0.80). The relative risk of CLABSI in the SD group was 0.502 (95% CI: 0.340-0.730; P < .001). If SDs are used on all catheters, the decreased rate of CLABSIs observed would calculate to a cost savings of US$4070 to US$39 600 per 1000 catheter days. After successful implementation of the SD, we observed significant reductions in CLABSI rates and a sustained reduction in the subsequent 6 years. CONCLUSION: Use of SDs is associated with a significant decrease in CLABSI rates in adult ICU patients compared to CHGIS dressings, with an estimated cost savings of US$4070 to US$39 600 per 1000 catheter days.

Symptomatic, Radiological, and Quality of Life Outcome of Paraesophageal Hernia Repair With Urinary Bladder Extracellular Surgical Matrix: Comparison With Primary Repair.

INTRODUCTION: Paraesophageal hernia repairs are prone to recurrence and mesh reinforcement is common. Both biologic and prosthetic meshes have been used. We report a comparison of a new type of biologically derived graft, Gentrix Surgical Urinary Bladder Matrix (UBM). METHODS: The medical records of 65 patients who underwent paraesophageal hernia repair (PEHR) were reviewed. Primary data points included demographics, first-time or recurrent hernia, operative approach, graft or primary repair, operative time, and postoperative complications. Patients then underwent upper gastrointestinal series, completed the GERD-HRQL symptom severity questionnaire, and the SF-36 generic quality of life instrument. RESULTS: A total of 32 patients underwent graft-reinforced repair, 33 underwent primary repair. More patients in the UBM group were being treated for recurrent PEH. Demographic data and postoperative complications were similar. There was no difference in recurrence rates, size of recurrence, postoperative symptomatic or quality of life improvement. Patients who suffered recurrence in the primary repair group had more severe symptoms and a higher rate of dissatisfaction. Of the 3 patients with recurrences after Gentrix placement, reoperation demonstrated anterior failure where no reinforcement had occurred because of the posteriorly placed U-shaped graft. CONCLUSIONS: The use of UBM was not associated with an increased complications despite use in more difficult patients. Although there appeared to be no difference in recurrence rate or size, it was associated with less severe symptomatic recurrences. The U-shape configuration is prone to recurrence at the site of the repair not covered by the graft, suggesting that a keyhole configuration may be superior.

Renal Replacement Therapy in Severe Burns: A Multicenter Observational Study.

Acute kidney injury (AKI) after severe burns is historically associated with a high mortality. Over the past two decades, various modes of renal replacement therapy (RRT) have been used in this population. The purpose of this multicenter study was to evaluate demographic, treatment, and outcomes data among severe burn patients treated with RRT collectively at various burn centers around the United States. After institutional review board approval, a multicenter observational study was conducted. All adult patients aged 18 or older, admitted with severe burns who were placed on RRT for acute indications but not randomized into a concurrently enrolling interventional trial, were included. Across eight participating burn centers, 171 subjects were enrolled during a 4-year period. Complete data were available in 170 subjects with a mean age of 51 ± 17, percent total body surface area burn of 38 ± 26% and injury severity score of 27 ± 21. Eighty percent of subjects were male and 34% were diagnosed with smoke inhalation injury. The preferred mode of therapy was continuous venovenous hemofiltration at a mean delivered dose of 37 ± 19 (ml/kg/hour) and a treatment duration of 13 ± 24 days. Overall, in hospital, mortality was 50%. Among survivors, 21% required RRT on discharge from the hospital while 9% continued to require RRT 6 months after discharge. This is the first multicenter cohort of burn patients who underwent RRT reported to date. Overall mortality is comparable to other critically ill populations who undergo RRT. Most patients who survive to discharge eventually recover renal function.

Hypertrophic Scar Severity at Autograft Sites Is Associated With Increased Pain and Itch After Major Thermal Burn Injury.

Approximately three quarters of major thermal burn injury (MThBI) survivors suffer from hypertrophic scarring (HTS) and over half experience chronic pain or itch. In survivors of MThBI, HTS and chronic pain or itch are considered one of the greatest unmet challenges of postburn injury care and psychosocial reintegration. Although scarring, itch, and pain have been clinically associated, there are no prospective, multisite studies examining tissue autograft site pain or itch and scar outcomes. The authors collected a representative cohort (n = 56) of MThBI survivors who received autografting within 14 days of injury and evaluated graft-site pain or itch severity (0-10 Numeric Rating Scale) and HTS using a validated scar photograph assessment scale 6 months following MThBI. Given that stress is known to influence wound healing, the authors also assessed the relationship between previous trauma exposure, peritraumatic stress, preburn overall health (SF-12), scarring, and chronic pain or itch severity using Spearman's correlation. Association between HTS and chronic pain or itch was significant in a linear regression model adjusted for age, sex, and ethnicity (ß = 0.2, P = .033 for pain, ß = 0.2, P = .019 for itch). Results indicate that prior trauma exposure is inversely correlated (r = -.363, P = .030) with scar severity, but not pain or itch severity 6 months after MThBI. Study results suggest that preburn chronic pain or itch is associated with pathological scarring 6 months following MThBI. Results also indicate that stress may improve scarring after MThBI. Further work to understand the mechanisms that underlie both HTS and chronic pain or itch and their relationship to chronic stress is critical to the development of novel therapies to assist burn survivors recover.

High-volume hemofiltration in adult burn patients with septic shock and acute kidney injury: a multicenter randomized controlled trial.

BACKGROUND: Sepsis and septic shock occur commonly in severe burns. Acute kidney injury (AKI) is also common and often results as a consequence of sepsis. Mortality is unacceptably high in burn patients who develop AKI requiring renal replacement therapy and is presumed to be even higher when combined with septic shock. We hypothesized that high-volume hemofiltration (HVHF) as a blood purification technique would be beneficial in this population. METHODS: We conducted a multicenter, prospective, randomized, controlled clinical trial to evaluate the impact of HVHF on the hemodynamic profile of burn patients with septic shock and AKI involving seven burn centers in the United States. Subjects randomized to the HVHF were prescribed a dose of 70 ml/kg/hour for 48 hours while control subjects were managed in standard fashion in accordance with local practices. RESULTS: During a 4-year period, a total of nine subjects were enrolled for the intervention during the ramp-in phase and 28 subjects were randomized, 14 each into the control and HVHF arms respectively. The study was terminated due to slow enrollment. Ramp-in subjects were included along with those randomized in the final analysis. Our primary endpoint, the vasopressor dependency index, decreased significantly at 48 hours compared to baseline in the HVHF group (p = 0.007) while it remained no different in the control arm. At 14 days, the multiple organ dysfunction syndrome score decreased significantly in the HVHF group when compared to the day of treatment initiation (p = 0.02). No changes in inflammatory markers were detected during the 48-hour intervention period. No significant difference in survival was detected. No differences in adverse events were noted between the groups. CONCLUSIONS: HVHF was effective in reversing shock and improving organ function in burn patients with septic shock and AKI, and appears safe. Whether reversal of shock in these patients can improve survival is yet to be determined. TRIAL REGISTRATION: Clinicaltrials.gov NCT01213914 . Registered 30 September 2010.

Pain and itch outcome trajectories differ among European American and African American survivors of major thermal burn injury.

More than half of individuals experiencing major thermal burn injury (MThBI) receive an autologous skin graft (autograft), in which skin is removed from a healthy "donor" site and transplanted to the burn site. Persistent pain and itch at the graft site are major causes of suffering and disability in MThBI survivors. African Americans have a higher risk of MThBI, and in other clinical settings African Americans experience a greater burden of pain and itch relative to European Americans. However, to our knowledge, ethnic differences in skin graft site pain and itch outcomes after MThBI have not been assessed. We evaluated skin graft site pain and itch severity (0-10 Numeric Rating Scale [NRS]) over 1 year in a prospective multicenter cohort sample of African Americans and European Americans. In adjusted linear mixed models, African Americans experienced a slower rate of pain resolution in the acute phase of recovery (ß = -0.05 vs -0.08 NRS points per day, P < 0.001), which resulted in a higher pain severity in the persistent phase of recovery (NRS mean difference = 1.21, 95% confidence interval [0.12-2.29]), although not statistically significant after correction for multiple comparisons. African Americans also experience greater itch severity in 6 weeks to 12 months after burn injury compared with European Americans (NRS mean difference = 1.86 [0.80-2.93]), which results from a faster rate of itch development in African Americans in the acute recovery phase after burn injury. Future studies may improve outcomes in African Americans and lead to new pathogenic insights that benefit all burn injury survivors.

Chronic Pain and Itch are Common, Morbid Sequelae Among Individuals Who Receive Tissue Autograft After Major Thermal Burn Injury.

OBJECTIVE: Pain and itch symptoms are common after major thermal burn injury (MThBI)-requiring tissue autografting. To our knowledge, no prospective longitudinal studies have characterized pain and itch outcomes after tissue autografting and associations between and functional interference caused by such symptoms. MATERIALS AND METHODS: We prospectively evaluated burn graft site and tissue donor site pain and itch severity (0 to 10, numeric rating scale) over 1 year among a representative cohort of MThBI survivors (n=96) who received tissue autografting within 14 days of MThBI. RESULTS: Nearly all participants had moderate or severe burn pain at the time of enrollment. Most individuals experienced an upper extremity burn with donor tissue taken from thigh. Persistent moderate or severe burn graft site pain declined thereafter, but remained common, with 25/90 (28%), 24/77 (31%), and 17/82 (21%) experiencing moderate or severe pain at 6 weeks, 3 months, and 6 months, respectively. Although there was improved function after immediate postinjury decline in all participants, those who had moderate or severe pain showed worse functional outcomes at each timepoint. Significant correlations were present between itch and pain burden over time at the same site (ie, autograft site r=0.629, P<0.01) and also across sites (ie, autograft and donor site itch r=0.552, P<0.01). DISCUSSION: Pain and itch are common after MThBI, are temporally and spatially concordant and cause significant impact on daily function. Further studies are needed to better understand pain and itch symptom pathogenesis after MThBI, to reduce the tremendous suffering and decline.

An Analysis of Inhalation Injury Diagnostic Methods and Patient Outcomes.

The purpose of this study was to compare patient outcomes according to the method of diagnosing burn inhalation injury. After approval from the American Burn Association, the National Burn Repository Dataset Version 8.0 was queried for patients with a diagnosis of burn inhalation injury. Subgroups were analyzed by diagnostic method as defined by the National Burn Repository. All diagnostic methods listed for each patient were included, comparing mortality, hospital days, intensive care unit (ICU) days, and ventilator days (VDs). Z-tests, t-tests, and linear regression were used with a statistical significance of P value of less than .05. The database query yielded 9775 patients diagnosed with inhalation injury. The greatest increase in mortality was associated with diagnosis by bronchoscopy or carbon monoxide poisoning. A relative increase in hospital days was noted with diagnosis by bronchoscopy (9 days) or history (2 days). A relative increase in ICU days was associated with diagnosis according to bronchoscopy (8 days), clinical findings (2 days), or history (2 days). A relative increase in VDs was associated with diagnosis by bronchoscopy (6 days) or carbon monoxide poisoning (3 days). The combination of diagnosis by bronchoscopy and clinical findings increased the relative difference across all comparison measures. The combination of diagnosis by bronchoscopy and carbon monoxide poisoning exhibited decreased relative differences when compared with bronchoscopy alone. Diagnosis by laryngoscopy showed no mortality or association with poor outcomes. Bronchoscopic evidence of inhalation injury proved most useful, predicting increased mortality, hospital, ICU, and VDs. A combined diagnosis determined by clinical findings and bronchoscopy should be considered for clinical practice.

Clopidogrel is not associated with increased bleeding complications after full-mouth extraction: A retrospective study.

BACKGROUND: To the authors' knowledge, the effect of clopidogrel on bleeding complications during full-mouth extraction has not been studied. The authors aimed to determine the safety of continued use of clopidogrel during full-mouth extraction. METHODS: The authors performed a retrospective study of consecutive patients undergoing full-mouth extraction who were taking aspirin, clopidogrel, a combination of aspirin and clopidogrel, or neither. The main study outcomes in the 4 study groups were estimated blood loss, transfusion requirements, and complications. The authors also examined the correlation between the number of teeth extracted and estimated blood loss in various groups. RESULTS: Seventy-one patients underwent full-mouth extraction with removal of an average of 19 teeth. The authors excluded 3 patients owing to lack of data regarding blood loss. Of the remaining 68 patients, 25 were using aspirin, 12 were using clopidogrel, 9 were using both aspirin and clopidogrel, and 22 had discontinued the use of antiplatelets. There was no significant difference in the number of teeth extracted (P = .283) and estimated blood loss (P = .111) among the 4 groups. The authors found a significant moderate correlation between the number of teeth extracted and estimated blood loss in the group using aspirin (r = 0.537; P = .006) and in the group using clopidogrel, whether alone or in combination with aspirin (r = 0.535; P = .012), but not in the group who discontinued the use of antiplatelets. There was no need for blood transfusion in any patient. CONCLUSIONS: The results of this study provide limited evidence to suggest that continuation of clopidogrel during full-mouth extraction and preprosthetic surgery may be safe and does not appear to be associated with a significant risk of bleeding. PRACTICAL IMPLICATIONS: Clopidogrel therapy during full-mouth extraction is not associated with significant bleeding complications and may be continued in patients who have a high risk of experiencing a cardiac event.

Recombinant Activated Factor VII Significantly Reduces Transfusion Requirements in Cardiothoracic Surgery.

BACKGROUND: The off-label use of recombinant activated factor VII (rFVIIa) for intractable bleeding is associated with a risk of thrombotic events. The objective of this study was to evaluate the incidence and predictors of rFVIIa-related thrombotic events and its efficacy in the reduction of transfusion requirements during various surgeries. METHODS: Ninety-two cases received rFVIIa for uncontrollable bleeding despite medical and surgical hemostasis. The incidence and risk factors of thrombotic events were analyzed. Blood products transfused in the 24 h before and after rFVIIa injection were calculated. Subgroup analysis was performed to see which types of surgeries benefited most from rFVIIa. RESULTS: The main indication for rFVIIa administration was uncontrollable bleeding during cardiothoracic surgery followed by coagulopathy due to liver failure followed by neurosurgical procedures. Requirements of blood products after rFVIIa decreased significantly by 45 % (p = 0.012), 52 % (p = 0.0001), and 75 % (p = 0.0001) for red blood cells, plasma, and cryoprecipitate, respectively. Subgroup analysis showed that cardiothoracic surgery was the sole group that benefited from rFVIIa with a reduction in transfusion of red blood cells (p = 0.013), plasma (p = 0.0001), and cryoprecipitate (p = 0.0001). Thrombotic events occurred in 9.8 % of the cases mostly on the arterial side (89 %) and have not contributed to mortality. CONCLUSION: rFVIIa can significantly reduce transfusion requirements when given for intractable bleeding during cardiothoracic surgery at the expense of thrombotic events in approximately one tenth of the cases. Further prospective studies are necessary to study if this effect of rFVIIa is translated to a favorable outcome.

Lingual traction to facilitate fiber-optic intubation of difficult airways: a single-anesthesiologist randomized trial.

PURPOSE: Flexible fiber-optic bronchoscope-guided orotracheal intubation is a valuable technique with demonstrated benefits in the management of difficult airways. Despite its popularity with anesthesia providers, the technique is not fail-safe and airway-related complications secondary to failed intubation attempts remain an important problem. We sought to determine the effect of incorporating lingual traction on the success rate of fiber-optic bronchoscope-guided intubation in patients with anticipated difficult airways. METHODS: In this prospective, randomized, cohort study, we enrolled 91 adult patients with anticipated difficult airways scheduled for elective surgery to undergo fiber-optic bronchoscope-guided orotracheal intubation alone or with lingual traction by an individual anesthesiologist after induction of general anesthesia and neuromuscular blockade. A total of 78 patients were randomized: 39 patients to the fiber-optic bronchoscope-guided intubation with lingual traction group and 39 patients to the fiber-optic bronchoscope-guided intubation alone group. The primary endpoint was the rate of successful first attempt intubations. The secondary outcome was sore throat grade on post-operative day 1. RESULTS: Fiber-optic intubation with lingual traction compared to fiber-optic intubation alone resulted in a higher success rate (92.3 vs. 74.4 %, χ (2) = 4.523, p = 0.033) and greater odds for successful first attempt intubation (OR 4.138, 95 % CI 1.041-16.444, p = 0.044). Sore throat severity on post-operative day 1 was not significantly different but trended towards worsening grades with lingual traction. CONCLUSIONS: In this study, lingual traction was shown to be a valuable maneuver for facilitating fiber-optic bronchoscope-guided intubation in the management of patients with anticipated difficult airways.

Late and very late drug-eluting stent thrombosis in the immediate postoperative period after antiplatelet withdrawal: a retrospective study.

BACKGROUND: Late (31-360 days after deployment) and very late (>360 days after deployment) stent thrombosis is a feared complication after drug-eluting stent (DES) deployment. The American College of Cardiology/American Heart Association guidelines recommend dual antiplatelet therapy for 12 months due to the lack of protection beyond this period in randomized trials. The perioperative period is a unique state of generalized hypercoagulability which can predispose people to DES thrombosis when combined with the rebound hypercoagulable effect of antiplatelet withdrawal. METHODS: A retrospective chart review was performed to detect incidences of late and very late postoperative DES thrombosis after elective noncardiac surgery. Only definite and probable cases of stent thrombosis were included. All cases were analyzed for patient demographics, comorbidities, type of surgery, intervention history, preoperative antiplatelets management, postoperative course and outcome. RESULTS: A total of six patients with prior DES deployment (10-42 months earlier, average 30 months) developed DES thrombosis (five very late and one late) in the immediate postoperative period. All patients had stable coronary artery disease and were cleared for surgery (intermediate cardiac risk surgery) by their cardiologist. In all patients, antiplatelets were discontinued 4-7 days (average 5.6 days) prior to surgery to minimize operative bleeding. Five of six patients developed ST-segment elevation myocardial infarction. Half of the patients had simultaneous two-vessel DES thrombosis and two cases had single vessel thrombosis. Three patients developed ventricular fibrillation and cardiac arrest. One-third of the patients died during the index hospitalization. Coronary thrombectomy and angioplasty was successful in the remaining four cases. The incidence of postoperative late and very late DES thrombosis among all patients undergoing noncardiac surgery who were older than 40 years was 0.006%. CONCLUSION: Caution should be exercised when attempting to withdraw antiplatelets preoperatively in patients with DES even when the recommended 12-month period of dual antiplatelet therapy (DAPT) has elapsed. The significant morbidity and mortality of this complication warrants further research to study the ideal perioperative management of antiplatelets in patients with prior DES deployment over 1 year who are still receiving DAPT.

Effects of repetitive exposure to anesthetics and analgesics in the Tg2576 mouse Alzheimer's model.

The use of anesthetics and sedatives has been suggested to be a contributor to Alzheimer's disease neuropathogenesis. We wanted to address the in vivo relevance of those substances in the Tg2576 Alzheimer's mouse model. Tg7526 mice were anesthesia-sedated for 90 min once a week for 4 weeks. Y maze, Congo Red, and amyloid beta (Aß) immunochemistry were performed. We did not find any significant change in the navigation behavior of the exposed mice compared to the controls. Significantly less deposition of Aß in the CA1 area of the hippocampus and frontal cortex of mice exposed to isoflurane, propofol, diazepam, ketamine, and pentobarbital was observed. In the dentate gyrus, Aß deposition was significantly greater in the group treated with pentobarbital. Congo Red staining evidenced significantly fewer fibrils in the cortex of mice exposed to diazepam, ketamine, or pentobarbital. The adopted repetitive exposure did not cause a significant detriment in Tg7526 mouse.

The use of isoproterenol and phenytoin to reverse torsade de pointes.

Torsade de pointes is a form of polymorphic ventricular tachycardia that differs from other forms of ventricular tachycardia in its morphology, precipitating factors, and therapeutic approach. Its recognition is of utmost importance, as the standard anti-arrythmic drugs not only might be ineffective in its termination but also may aggravate it. Herein, we report a case of antipsychotic-induced torsade de pointes and describe the use of magnesium sulfate, isoproterenol, and phenytoin and their proposed mechanism of action.

Knee strength retention and analgesia with continuous perineural fentanyl infusion after total knee replacement: randomized controlled trial.

PURPOSE: Despite providing adequate pain relief, a femoral nerve block can induce postoperative muscle weakness after total knee arthoplasty (TKA). Fentanyl has been shown to have peripheral effects but has not been used as a perineural infusate alone after TKA. METHODS: Sixty patients scheduled for TKA were randomized to one of three blinded groups: a continuous 24 h infusion of either fentanyl 3 µg/ml, ropivacaine 0.1%, or 0.9% normal saline through a femoral nerve sheath catheter at 10 ml/h. The main outcome was maximum voluntary isometric contraction (MVIC) in the quadriceps femoris (knee extension), measured by a handheld dynamometer (Nm/kg). Other variables assessed were preoperative and postoperative visual analog scale (VAS) scores, hamstrings MVIC (knee flexion), active range of motion of the operative knee, distance ambulated, incidence of knee buckling, supplemental morphine usage, postoperative side effects, and serum fentanyl levels. RESULTS: Quadriceps MVIC values were significantly greater in the fentanyl group compared to the group that received ropivacaine (median values, 0.08 vs. 0.03 Nm/kg; p = 0.028). The incidence of postoperative knee buckling upon ambulation was higher in the ropivacaine group compared to the fentanyl group, although not statistically significant (40% vs. 15 %, respectively; p = 0.077). VAS scores while ambulating were not significantly different between the fentanyl group and the ropivacaine group (p = 0.270). Postoperative morphine consumption, nausea and vomiting, and resting VAS scores were similar among the three groups. CONCLUSIONS: A continuous perineural infusion of fentanyl produced greater strength retention than ropivacaine post-TKA.