Evaluación de la incidencia de temblores en la sala de recuperación postanestésica / Evaluation of the incidence trembling in the recovery room postanesthtic / Avaliação da incidência de tremores na sala de recuperação posanestesica

Los temblores son una complicación frecuente, desagradable y que pueden relacionarse a un aumento de la morbilidad del período postoperatorio. El propósito de este estudio fue determinar la frecuencia de presentación de temblores en el postoperatorio inmediato. Pacientes y métodos: Se estudiaron 119 pacientes adultos, operados de coordinación una vez que ingresaron a la Sala de Recuperación Postanestésica (SRPA). Se consignó la presencia y severidad (grado I a IV) de temblores al ingreso y luego cada 15 minutos. Se trataron mediante medidas de recalentamiento externo, ondansetrón y meperidina, de manera escalonada cada 15 minutos. Resultados: hubo 24 (21.2 %) pacientes con temblores postoperatorios, 17/24 (71%) asociados a hipotermia. En 8 (33,3%) pacientes el temblor fue grado I, en 2 (8,3%) fueron grado II, y en 14 (58,3%) fueron grado III. En todos los casos cedieron con el tratamiento pautado y no más allá de los 45 minutos. Conclusiones: Los temblores fueron una complicación frecuente en la SRPA, asociados a hipotermia en la mayor parte de los casos, pero de duración limitada, y fácilmente tratables.

Trembling are frequent, unpleasant complication and can relate to increased morbidity postoperative period. The purpose of this study was to determine the frequency of occurrence of earthquakes in the immediate postoperative period. Patients and Methods: 119 adult patients operated coordination once entered the recovery room (PACU) were studied. the presence and severity (grade I to IV) of tremors at admission and then every 15 minutes was recorded. They were treated by external measures, ondansetron and meperidine overheating, staggered every 15 minutes. Avaliação da incidência de tremores na sala de recuperação posanestesica.

Tremores é uma complicação freqüente, desagradável e que pode relacionar-se a um aumento da morbilidade do período posoperatorio. O propósito deste estudo foi determinar a freqüência de manifestação de tremores no posoperatorio imediato. Pacientes e métodos: Estudaram-se 119 pacientes adultos, de cirurgias eletivas que chegaram à Sala de Recuperação Posanestesica (SRPA). Registraram-se a presença e severidade (grado I a IV) de tremores ao ingresso e cada 15 minutos. O tratamento foi: medidas de aquecimento externo, ondansetron e meperidina de maneira alternativa cada 15 minutos. Resultados. Teve 24 (21.2%) de pacientes com tremores posoperatorio, 17/24 (71%) associados à hipotermia. Em 8 (33,3%) pacientes o tremor foi grado I, em 2 (8,3%) foi grado II, em 14 (58,3%) grado III. Todos os casos acalmaram com o tratamento pautado nos primeiros 45 minutos. Conclusões. Os tremores foram uma complicação freqüente em SRPA, associado à hipotermia na maioria dos casos, com duração limitada e de fácil tratamento.

Outcome after elective infrarenal aortic aneurysm surgery.

We conducted a prospective case series study to investigate the causes of and factors influencing morbidity and mortality in 102 consecutive patients after elective infrarenal abdominal aneurysm (AAA) surgery between 1992 and 1995. Preoperative factors (demographics, risk factor indexes, electrocardiographic findings, ejection fraction, and stress imaging scans were indicated) and intraoperative factors (duration of surgery, size of aneurysm, complications, units of blood transfused, and additional procedures performed) were recorded. Patients were admitted to the intensive care unit (ICU) for at least 24 hours and followed for 30 days postoperatively. The mortality rate was 4.9%, due in all cases to multiorgan dysfunction syndrome (MODS). Death was preceded by colon ischemia (two patients), intraabdominal bleeding (two patients), or sepsis (one patient). Only the preoperative blood urea nitrogen correlated with mortality (p = 0.042). Complications occurred in 59% of patients in the ICU and involved the cardiovascular system in 83% of them (heart rate > 90 bpm in 49%). On multivariate analysis, only duration of surgery was associated with ICU complications (p = 0.018). No complication resulted in mortality. Ward complications occurred in 13%, and 5% of these patients required readmission to the ICU. Although cardiac complications are considered the major cause of mortality after infrarenal AAA surgery, all five deaths in the present series were due to MODS. Preoperative screening should be more selective, and intraoperative and postoperative care should be stressed.

Acute beriberi following liver transplantation.

Patients scheduled for orthotopic liver transplantation (OLT) undergo extensive routine preoperative cardiac assessment. We describe a 32-year-old male who underwent uneventful OLT for endstage liver failure on the basis of chronic hepatitis C and alcoholism. Despite a normal preoperative cardiac workup, the patient developed acute pulmonary edema on the second postoperative day. A diagnosis of beriberi was entertained and confirmed by (1) the thiamine diphosphate effect and (2) the dramatic response to intravenous thiamine. Possible precipitating factors are described. Thiamine, which has no significant toxicity, should probably be routinely supplemented in all patients undergoing OLT, especially those with a previous history of alcohol abuse.

Facilitation of mechanical ventilation in status asthmaticus with continuous intravenous thiopental.

Mechanical ventilation in status asthmaticus is associated with a significant mortality and morbidity. To facilitate intermittent positive pressure ventilation (IPPV), we have used continuous IV thiopental (thiopentone) together with traditional ventilatory techniques. With this policy, we were able to achieve rapid correction of arterial blood gas tensions in a group of 20 severe asthmatics requiring IPPV. By 1 hour, peak airway pressure (PAP) had fallen from 58.6 +/- 15.7 to 30.2 +/- 10.9 cm H2O (p less than 0.001). During the same period, PaCO2 fell from 51.3 +/- 15.3 to 40.17 +/- 8.2 mm Hg (p less than 0.05) and pH rose from 7.25 +/- 0.1 to 7.33 +/- 0.1 (p less than 0.001). Morbidity was low and in particular, no episode of barotrauma was noted. All patients survived the acute attack and were successfully liberated from the ventilator. We conclude that these results are largely attributable to our use of early and continuous IV anesthesia induced by thiopental.

[Sudeck's bone atrophy after leg phlebography - a case study of an unusual complication (author's transl)]. / Sudecksche Knochenatrophic nach Beinphlebographie - Fallstudie einer aussergewöhnlichen Komplikation.

In a 39-year old man, a painful oedema had formed at the back of the foot perimalleolary one day after paravasal contrast medium injection following ascending phlebography. 8 weeks later, the x-ray film showed a maculate Sudeck's bone atrophy in the region of the toes, ankles and the heel. Sudeck's bone atrophy had obviously developed on account of a specific vegetative reactivity, subsequent to the local inflammation.

[The surgically treated aortic valve defect in the pre- and postoperative x-ray]. / Das operierte Aortenvitium im Röntgennativbild.

Within a postoperative control study of 81 patients with aortic valvular disease 14 patients showed cardiomegaly. This might be caused by several reasons as insufficiency of valvular prosthesis, coronary disease, adipositas or wrong digitalis application. All patients with pulmonary congestion, except one, showed a complete removal of congestion, because the wide position of the vessels was not yet fixed.

[The value of xerotomography of the lung and mediastinum in routine diagnosis (author's transl)]. / Der Wert der Xerotomographie von Lunge und Mediastinum in der Routinediagnostik.

Using controlled case material (n = 55), the weighted value of xerotomography is compared with that of conventional film tomography for the examination of mediastinum and lung. The validity of information of both methods for the final diagnosis is compared. In the visualisation of bronchial units and vascular structures, xerotomography is slightly superior to tomography with silver halogenide films, due to high degree of sharpness of detail, great object range and amplification of the marginal areas. Nodular hilar processes which are in spatial relationship to plane, pulmonary infiltrations or are overshadowed by the cardiac shadow, can be better clarified via conventional technique because of the differences in film density. Overshadowing of linear structures can simulate calcifications in the xeroradiographic image. In our opinion, a combination of film tomography in two planes with xerotomography in an optimal sectional plane can be recommended as a suitable procedure.

[The radiographic appearances following correction of left-to-right shunts (author's transl)]. / Das operierte Rezirkulationsvitium im Röntgennativbild.

Amongst 22 patients with corrected left-to-right shunts, a diminution in heart size and reduction in central pulmonary arteries and pulmonary plethora was found in about half the patients. A good operative result can be expected, particularly in younger patients with less severe lesions, where the vessels had not been subjected to a high pressure for a long period. The failure of vessels to return to normal is assurmed to be due to changes in the vessel walls. Possible causes for persistent cardiomegaly are, in addition to persistent shunts, coronary artery disease, obesity, inadequate digitalisation and aortic and mitral insufficiency.

[Magnification technique in peripheral angiography (author's transl)]. / Vergrösserungstechnik in der peripheren Angiographie.

Fourteen exactly similar conventional and magnified serial angiograms were compared and the advantages and disadvantages of magnification angiography are discussed. Particular attention was paid to exact comparability of the series in order to make the analysis valid. In three patients small end-vessels and collaterals were visible on the magnification angiogram which could not be seen on the ordinary series even in retrospect. Macro-angiography was also valuable in cases of microsurgery, both before and after operation. Considering the well-known disadvantages of magnification angiography, such as increased radiation and cost, its use appears to be indicated only for the elucidation of special problems.

[Calcified fibroadenoma of the breast (author's transl)]. / Verkalkte Fibroadenome der Mamma.

Demonstration of calciefied fibroadenomas of the breast of a seldom size. Short differential diagnosis between the mostly benign macrocalcifications and the typical microcalcifications in breast cancer.

[Fibrinolytic therapy in deep venous thrombosis of the upper and lower extremity]. / Fibrinolytische Therapie bei tiefen Venenthrombosen der oberen und unteren Extremität

Fibrinolytic therapy was carried out in 59 patients suffering from a total of 60 deep venous thromboses of the iliac segment (n = 24), the femoropopliteal segment (n = 18), the deep calf veins (n = 2), or the subclavian vein (n = 16). 46 patients received streptokinase (SK), 4 were given urokinase (UK), and 10 were treated with streptokinase followed by urokinase (SK + UK). The duration of fibrinolytic therapy was between 19 and 596 hours (x = 166 +/- 111 hrs). Phlebographic examination was used to determine the location of the thrombotic occlusion as well as to evaluate therapeutic results. To assure sufficient anticoagulatory protection during therapy with streptokinase the dose of streptokinase was either reduced by steps of 20,000 U/hr to a minimum of 40,000 U/hr or heparin was added as a continuous infusion. Urokinase was administered with a mean loading dose of 75,000 IU followed by an average maintenance dose of 40,000 IU/hr; it was always given in combination with heparin. When therapeutic success was graded as complete/partial/no recanalisation, the following results were obtained: thrombotic occlusion up to 1 week old 35%/48%/17%; up to 2 weeks old 57%/14%/29%; 3 or 4 weeks old 12%/38%/50%; older than 4 weeks 13%/37%/50%. The two most common side effects were a fall of the hemoglobin and a rise of body temperature. Treatment with SK had to be interrupted for bleeding in two cases. One patient diet after rupture of the liver and of the spleen following development of subcapsular hematoma in these organs, 3 patients survived pulmonary embolism without major long-term impairment. Considering medical and social aspects (preservation of capability for working in young adults) it appears justified to administer fibrinolytic agents up to a thrombus age of 14 days, in some cases even up to a thrombus age of 28 days. Good results in cases of deep vein thrombosis of the lower limbs are often obtained only when fibrinolytic therapy is extended beyond 96 hours. It should be performed in intensive care units only. Follow-up examinations of the venous drainage capacity up to 2 years after fibrinolytic therapy document the good therapeutic effect that is warrented by streptokinase or urokinase induced complete recanalisation.

[Combined carotid and femoral angiography in arterial occlusive disease (author's transl)]. / Kombinierte Karotis und Femoralisangiographie bei arterieller Verschlusskrankheit

"Asymptomatic" carotid stenosis with a murmur is an indication for carotid angiography, particularly in patients with peripheral arterial occlusive disease. Carotid angiography in the neck, carried out in two planes, makes it possible to differentiate different types of stenosis. Plaques and ulcerating strictures are a source of micro-emboli. The extent and localisation of extracranial carotid stenoses must be precisely defined because of their haemodynamic effects, particularly before major vascular surgery, which may result in a transient fall in blood pressure. Carotid angiography can be combined with femoral angiography in patients with peripheral arterial occlusive disease. In our experience, the combined angiography does not result in any increase in the complication rate. This experience is based on 38 patients seen in the last 14 months.