Cetrimide-chlorhexidine-induced multiorgan failure in surgery of pulmonary hydatid cyst.

Savlon (0.5% cetrimide/0.05% chlorhexidine) is used as a scolicidal during surgery of hydatid cysts. It is considered a safe and effective agent. However, there are no recommendations for the appropriate concentration or dosage of these agents. Previously reported to cause severe metabolic acidosis, its effects on the pulmonary system have not been explored. We present a case of acute lung injury and respiratory distress along with acute cardiopulmonary distress, severe metabolic acidosis, and renal failure following its use during surgical removal of pulmonary hydatid cyst. The agent may act as a chemical sclerosant causing pulmonary parenchymal damage through bronchial openings present in the pericyst. Till safe dose limits are known, use of this agent should be limited, especially in large or multiple cyst surgery.

The effect of oral topical anesthesia on the characteristics of voice.

OBJECTIVES/HYPOTHESIS: Although oral topical anesthesia is used routinely before rigid laryngeal endoscopy, no study has determined whether oral topical anesthesia changes voice quality. Our goal was to determine the effects of topical anesthesia on voice. STUDY DESIGN: Prospective cohort study. METHODS: Adult patients presenting to a laryngology practice who required rigid laryngeal endoscopy as part of the routine clinical visit were eligible for the study. Voices were recorded before and after oral topical benzocaine (14%)/butamben (2%)/tetracaine (2%) (ie, cetacaine) spray. Consensus auditory perceptual evaluation of voice (CAPE-V) protocol was used for the voice recordings and was the primary outcome measure. Recordings were presented randomly to two blinded speech-language pathologists specialized in voice. Secondary outcome measures were fundamental frequency (F0), jitter, shimmer, and noise-to-harmonics ratio (N/H) on sustained /i/ and speaking F0. RESULTS: One hundred two patients participated in the study. There was no significant difference in CAPE-V measurements before and after topical anesthesia for all six attributes: overall severity (P = 0.145), roughness (P = 0.214), breathiness (P = 0.761), strain (P = 0.053), pitch (P = 0.301), and loudness (P = 0.320). There was no significant difference in jitter (P = 0.315), shimmer (P = 0.942), N/H (P = 0.128), and speaking F0 (P = 0.320). F0 /i/ decreased by a mean of 4.8Hz, which was statistically significant (P = 0.003), but probably not clinically significant. CONCLUSION: There was no clinically significant voice change after oral topical anesthesia.

Cetacaine induced methemoglobinemia: overview of analysis and treatment strategies.

Methemoglobin is formed upon iron oxidation of the heme molecule from ferrous (Fe2+) to its ferric (Fe3+) state. Normal methemoglobin levels in the body vary between 1-2% of the total hemoglobin. Cause of methemoglobinemia can be inherited or acquired. Inherited causes include an enzymatic deficiency in the enzyme cytochrome b5 reductase where as acquired causes are most commonly from routinely used medications. Herein, we present to you a case of methemoglobinemia after Cetacaine (a benzocaine based topical anesthetic) utilization during a transesophageal echocardiography. Some of the other common potential inciting agents are also discussed here along with an overview of treatment strategies.

Detoxification of gold nanorods by conjugation with thiolated poly(ethylene glycol) and their assessment as SERS-active carriers of Raman tags.

We present an effective, low cost protocol to reduce the toxicity of gold nanorods induced by the presence of cetyltrimethylammonium bromide (CTAB) on their lateral surface as a result of the synthesis process. Here, we use thiolated methoxy-poly(ethylene) glycol (mPEG-SH) polymer to displace most of the CTAB bilayer cap from the particle surface. The detoxification process, chemical and structural stability of as-prepared mPEG-SH-conjugated gold nanorods were characterized using a number of techniques including localized surface plasmon resonance (LSPR), transmission electron microscopy (TEM) and surface-enhanced Raman spectroscopy (SERS). In view of future applications as near-infrared (NIR) nanoheaters in localized photothermal therapy of cancer, we investigated the thermal behaviour of mPEG-SH-conjugated gold nanorods above room temperature. We found a critical temperature at around 40 degrees C at which the adsorbed polymer layer is susceptible to undergo conformational changes. Additionally, we believe that such plasmonic nanoprobes could act as SERS-active carriers of Raman tags for application in cellular imaging. In this sense we successfully tested them as effective SERS substrates at 785 nm laser line with p-aminothiophenol (pATP) as a tag molecule.

Effectiveness of a non-surgical alternative to the Mules operation in sheep.

OBJECTIVE: To measure changes to the perineal bare area, local tissue reaction and healing responses of young sheep, following intradermal administration of cetrimide and polyvinylpyrrolidone (PVP), with and without ethanol, to the breech and tail. METHOD: A needle-less injector was used to deposit formulations containing 40 g/L cetrimide and 30 g/L PVP (group 2) or 20 g/L cetrimide, 30 g/L PVP and 15 g/L ethanol (group 3), within the dermis of the tail and the region surrounding the perineal bare breech area of groups (N = 8) of Merino weaner sheep. The dimensions of the perineal bare area (length, width and diagonal distances left and right) and tail width were recorded before and at intervals after treatment for 60 days. Observations of swelling and bruising and scab formation at the treatment sites were recorded for up to 35 days after treatment. Rectal temperatures were monitored for up to 35 days after treatment and bodyweight for up to 60 days after treatment. An untreated control group (group 1) was included. RESULTS: Comparison of day -3 and day 35 measurement data showed that both treated groups had significantly (P < 0.05) wider breech bare areas compared to the untreated controls and that group 2 sheep had significantly (P < 0.05) longer breech bare areas compared to group 3 sheep or to the untreated controls, which were not significantly different. At this time scabs were still firmly in place on many treated sheep. At day 35 there was no increase in tail bare area caused by either treatment. By day 60 there was no significant difference between the treated and control groups in either the breech or tail regions indicating that the changes present at day 35, were not permanent. Mean weight gain in the groups throughout the 60-day interval was unaffected by treatment. Intradermal treatment was associated with a significant elevation in body temperature. This effect lasted for 3 days and was associated with signs of discomfort and depressed appearance in at least some of the treated sheep. Bruising was mild to severe in all treated sheep within two days of treatment but was not evident in any sheep by day 21. Mild to moderate swelling was also associated with treatment but was not uniform across sheep in the groups. The tail of one sheep was severely swollen for several days. Swelling remained obvious in most treated sheep until day 14 but was not present at day 21. CONCLUSION: Under the conditions of this study intradermal injection of cetrimide had no permanent effect on bare area measurements on the breech or the amount of wool-bearing skin on the tail. It also caused signs of discomfort and pain that raise welfare concerns.

Assessment of welfare of suckling lambs following intradermal injection of cetrimide as a non-surgical alternative to conventional mulesing.

OBJECTIVE: To assess in suckling lambs the impact of intradermal injection of cetrimide, a quaternary ammonium compound formulated to induce non-surgical mulesing, on some physiological and behavioural indicators of welfare. PROCEDURES: We allocated 32 suckling lambs (9-11 weeks old) to three groups: (1) control (n = 10), (2) conventional surgical mules (n = 11) and (3) non-surgical mules (n = 11). Non-surgical mulesing was induced by intradermal injection of 4% (w/w) cetrimide + 3% (w/w) polyvinylpyrrolidone in water. Lambs were run in pens of four together with their dams. Haematology, cortisol, beta-endorphin and haptoglobin levels, and rectal temperature were monitored at least daily for the first 7 days after treatment, then weekly until day 28. Body weight was measured weekly and behaviour was measured every 15 min for 12 h on the day of treatment, then on days 1, 2, 4, 6, 12, 21 and 28 following treatment. RESULTS: The intradermal treatment induced local tissue swelling, systemic signs of severe inflammation, including high fever (> 41.0 degrees C) and elevated blood cortisol levels, by 12 h. Rectal temperatures were significantly elevated until 6 days after treatment, cortisol levels were elevated until 4 days after treatment, haptoglobin levels for at least 7 days after treatment and the neutrophil to lymphocyte ratio until 5 days after treatment. Peak cortisol values were comparable in mulesed lambs and lambs receiving the intradermal treatment, whereas the areas under the curves for cortisol and temperature were greater in lambs receiving the intradermal treatment than in mulesed lambs. Beta-endorphin levels were significantly elevated in mulesed sheep at 12 h. There was no effect of intradermal treatment on average daily gain, fibre diameter or beta-endorphin concentration. Mulesed lambs spent 44% of the time in abnormal behaviours (hunched standing, stiff walking, pawing, lateral lying and lying intention) on the day of treatment. On the day after treatment, lambs receiving the intradermal treatment spent 11% of the time (comparable to mulesed lambs) in abnormal behaviours. In comparison, control lambs spent 0.4% of their time in abnormal behaviours on the same day. CONCLUSIONS: The welfare of suckling lambs that were non-surgically mulesed by intradermal injection of cetrimide was measurably poorer than control lambs.

Effect of the non-steroidal anti-inflammatory drug, carprofen, on weaned sheep following non-surgical mulesing by intradermal injection of cetrimide.

OBJECTIVE: To assess in weaned lambs the palliative effects of the non-steroidal anti-inflammatory drug, carprofen, following intradermal injection of cetrimide to induce non-surgical mulesing. PROCEDURES: We allocated 40 weaned lambs (20-22 weeks old) to four groups of 10 animals: (1) control, 2) conventional surgical mules, (3) intradermal treatment and (4) intradermal treatment + carprofen. Non-surgical mulesing was induced by intradermal injection of 4% (w/w) cetrimide + 3% (w/w) polyvinylpyrrolidone in water. In group 4, carprofen (4 mg/kg, SC) was administered 1 h before intradermal treatment. Five weaners, including an animal from each treatment, were run in each pen. Neutrophil to lymphocyte ratio, cortisol, beta-endorphin and haptoglobin levels and rectal temperature were monitored at least daily for the first 7 days after treatment, then weekly until day 28. Body weight was measured weekly and behaviour was measured every 15 min for 12 h on the day of treatment, then on days 1, 2, 4, 6, 12, 21 and 28 following treatment. RESULTS: The intradermal treatment resulted in high fever and elevated blood cortisol by 12 h. Rectal temperatures were significantly elevated until 5 days after treatment, cortisol was elevated until 3 days after treatment, haptoglobin for at least 7 days after treatment and the neutrophil to lymphocyte ratio until 4 days after treatment. Average daily gain was depressed in the week following treatment. Abnormal behaviours (hunched standing, stiff walking, pawing, lateral lying and lying intention) were increased on the day of treatment and for 6 days post treatment. Carprofen reduced the time spent in abnormal behaviours by approximately two-thirds but did not ameliorate the physiological responses to the intradermal treatment. CONCLUSIONS: In weaner sheep, carprofen ameliorated the behavioural responses, but was unable to provide relief from the intense and sustained physiological responses to non-surgical mulesing by intradermal injection of cetrimide. Systemic side-effects may be unavoidable with formulations based on quaternary ammonium compounds that are designed to reduce the risk of fly strike in sheep by remodelling breech tissue through induction of tissue necrosis.

Methemoglobinemia after fiberoptic intubation in a patient with an unstable cervical fracture: a case report.

Methemoglobinemia, a condition associated with cyanosis and diminished pulse oximetry values, has been reported after use of local anesthetics to facilitate fiberoptic intubation. The majority of reports in the literature detail this development during diagnostic procedures such as endoscopy and bronchoscopy. A case of methemoglobinemia in a multiple-injury patient with an unstable compressive-flexion injury of the cervical spine undergoing fiberoptic intubation is presented. A literature review of this entity is also presented. The patient underwent fiberoptic intubation using topical pharyngeal anesthetics before planned cervical corpectomy, strut grafting and instrumentation. He became acutely cyanotic with abruptly diminished pulse oximetry readings. Subsequent blood gas analysis demonstrated methemoglobinemia. Intravenous methylene blue administration led to an uncomplicated resolution of the condition. Surgeons and anesthesiologists who manage such patients should be aware of methemoglobinemia, a rare but potentially fatal complication related to topical airway anesthetics.

Double-blind study on the effects of topical anesthesia on laryngeal secretions.

The application of topical anesthesia to the oropharynx is a common clinical practice during oral and nasal laryngoscopy. Clinically, questions have been raised about whether topical anesthesia alters laryngeal secretions, which distorts clinical impressions. A double-blind, placebo controlled design was employed to address this issue. Ten premenopausal women with healthy vocal folds and 10 premenopausal women with phonotraumatic lesions underwent oral videolaryngoscopic examinations on subsequent days under both anesthesia and placebo conditions, in counterbalanced order. Video segments were rated by three judges. Dependent variables were balling and pooling of secretions, as previously described in the literature. Statistical analyses failed to reveal any clear effect of topical anesthesia on either secretion balling or pooling for the collapsed data set, but one cannot exclude changes in individual cases. Moreover, there was no evidence that secretions were differentially affected by anesthesia across subject groups. Null results in this data set replicate and extend previously reported findings by other authors. An incidental but potentially interesting finding was that the order of treatment condition (anesthesia versus placebo first) seemed relevant for secretions: Subjects who received the anesthesia condition first tended to show more secretion balling in general, as compared with subjects who received the placebo condition first. Speculation is entertained regarding possible physiological pathways for these incidental findings, which could be relevant for some clinical practice.

The need for caution with topical anesthesia during endoscopic procedures, as liberal use may result in methemoglobinemia.

During upper gastrointestinal endoscopy, topical oropharyngeal anesthesia with lidocaine and/or benzocaine is used routinely by many endodscopists. Although such a practice is usually safe, there have been a number of reports of methemoglobinemia induced by topical anesthesia. Early treatment is extremely important as the development of methemoglobinemia is potentially fatal. Methemoglobinemia should be considered when oxygen desaturation occurs without another explanation. In this case series, we report 4 cases of methemoglobinemia that followed the liberal application of Cetacaine for ERCP. All patients recovered after appropriate treatment but these cases serve to highlight the potential problem, the importance of early recognition and treatment, and the most appropriate treatment options.

Tongue entrapment in an aluminum juice can.

Tongue entrapment in bottles and cans is rare, but occurs. The following is a case report of a 10-year-old female who got her tongue entrapped in an aluminum juice can. The anatomy of the tongue, complications from injury, and a proposed removal procedure are described.