Outpatient tympanomastoidectomy: factors affecting hospital admission.

BACKGROUND: Outpatient tympanomastoidectomy is common in many medical centers. However, failure of same-day discharge is often the result of postoperative nausea and vomiting (PONV). Many times this leads to hospital admission after tympanomastoidectomy, and it is often difficult to predict before surgery whether PONV will be an issue that impedes same-day discharge. OBJECTIVE: To determine the clinical factors correlated with the incidence of PONV requiring hospital admission after chronic ear surgery by hypothesizing that the complexity of a particular case, as measured using a 10-point scale, is predictive of surgical time or failure of same-day hospital discharge. STUDY DESIGN: Retrospective medical chart review of 103 patients having mastoidectomy with tympanoplasty for chronic otitis media over a 2-year period. METHODS: We recorded patient age, clinical data, surgical times, types of agents used for induction and maintenance of anesthesia, use of prophylactic antiemetic drugs, types and doses of analgesic agents, and PONV. Univariate and multivariate logistic regression analyses were performed to determine which variables were associated with PONV that required hospital admission. RESULTS: One third of patients studied were safely discharged from the hospital the day of surgery, and 92% were discharged within 23 hours. The most common cause for observation admission to the hospital was PONV. The only variable in multivariate analysis that significantly correlated with PONV mandating hospital admission after tympanomastoid surgery was a history of motion sickness or PONV (odds ratio, 5.21; P =.02). Although severity of disease did not correlate with length of hospital stay, it directly correlated with length of surgery. CONCLUSIONS: A history of PONV or motion sickness is predictive of PONV and length of hospital stay. Routine planning for a 23-hour overnight observation stay seems warranted for all patients undergoing tympanomastoidectomy, despite severity of disease.

Acceptance of an ABO-incompatible mismatched (AB(+) to O(+)) liver allograft with the use of daclizumab and mycophenolate mofetil.

Liver allograft survival rates of 50% to 60% are reported in blood group A, group B, group O (ABO)-incompatible mismatched grafts even when aggressive immunosuppressive protocols, including plasmapheresis, OKT(3), cyclophosphamide, cyclosporine, prostaglandin E(1), and steroids, are used. A 59-year-old woman, blood type O(+), required emergency retransplantation posttransplantation day 2 because of primary nonfunction of the liver allograft. A blood type AB(+) allograft was used. Induction immunosuppressive therapy included tacrolimus, mycophenolate mofetil, OKT(3) (muromonab-CD(3)), steroids, and prostaglandin E(1). In addition, plasmapheresis was performed daily for 9 days. OKT(3) and prostaglandin E(1) were also discontinued postoperative day 9. Biopsy-proven acute cellular rejection was diagnosed postoperative day 12 and was treated with double-dose OKT(3) (10 mg) for another 6 days. On the day OKT(3) was discontinued, daclizumab, 60 mg, was administered intravenously. This dose was repeated every 2 weeks for a total of 5 doses. At 1-year follow-up, the patient is doing very well with normal liver function. We are unaware of previous reports of the use of daclizumab and mycophenolate mofetil as part of an immunosuppressive protocol aimed to induce acceptance of ABO-incompatible mismatched liver allografts. Based on our experience with this case, it seems that mycophenolate mofetil is an adequate replacement for cyclophosphamide. We also believe daclizumab provided adequate protection at a critical time. Further experience with both these drugs is required to establish their role in ABO-incompatible mismatched liver allografts.

Endoscopic placement of nasoenteric feeding tubes in critically ill patients: a reliable alternative.

Spontaneous transpyloric passage of nasoenteric feeding tubes is often unsuccessful in critically ill patients due to gastric ileus. The purpose of this study was to evaluate the success rate of endoscopic placement of postpyloric nasoenteric tubes and the time required to achieve goal enteral nutritional support in critically ill patients with gastric ileus. Surgical ICU patients with gastric ileus, documented by recorded high gastric residual volumes via a nasogastric tube, were identified for placement of a nasoenteric postpyloric tube via esophagogastroduodenoscopy (EGD). EGD was performed bedside in the ICU, using intravenous sedation, for placement of a 43-inch (109 cm) 8 French tungsten-weighted nasoenteric tube with an inner stylet into the duodenum, and the tube was advanced as far distally as possible. Abdominal radiograph was obtained to confirm final tube position postprocedure. Enteral feedings were initiated immediately with a full-strength formula and increased to the goal enteral feeding rate as tolerated. Thirty-four patients underwent successful placement of postpyloric nasoenteric tubes by EGD. One procedure was aborted in a patient with adult respiratory distress syndrome (ARDS) who developed hypoxemia with gastric insufflation during the EGD. The mean time to achievement of goal enteral nutritional support was 20.8 hours. Tubes remained in place for a range of 6 to 37 days. Endoscopic placement of postpyloric enteral feeding tubes is highly successful, and allows for prompt achievement of goal enteral nutritional requirements. It has two main advantages: it eliminates the risk of patient travel to radiology for fluoroscopic placement, and allows for earlier initiation of enteral feedings because spontaneous passage of weighted nasoenteric tubes into the duodenum in critically ill patients is often unsuccessful.

Spontaneous splenic rupture following administration of granulocyte colony-stimulating factor (G-CSF): occurrence in an allogeneic donor of peripheral blood stem cells.

Granulocyte colony-stimulating factor (G-CSF) has been used to improve granulocyte count in chronic neutropenia and myelodysplasia, to minimize the incidence and duration of neutropenia during conventional chemotherapy, and to mobilize peripheral blood stem cells prior to leukapheresis for use in autologous and allogeneic marrow transplantation. The most common toxicity is bone pain, and other reactions such as inflammation at the site of injection have also occurred. In patients with chronic neutropenia, splenomegaly has been described with long-term use, and extramedullary hematopoiesis has also been reported. However, thus far, no life-threatening sequelae of these effects are found in the literature. We now describe a case of spontaneous splenic rupture four days following a six-day course of G-CSF therapy in an allogeneic donor of peripheral blood stem cells.

Gamma radiation-sterilized, triple-lumen catheters coated with a low concentration of chlorhexidine were not efficacious at preventing catheter infections in intensive care unit patients.

In a randomized, double-blind trial, gamma radiation-sterilized, chlorhexidine-coated triple-lumen catheters were compared with uncoated control catheters for their ability to prevent catheter infection in 254 intensive care unit patients. The chlorhexidine coating was not efficacious, and a rabbit model demonstrated that reduction of chlorhexidine activity by gamma radiation sterilization was the likely explanation for the failure.

Asymptomatic deep venous thrombosis in the trauma patient: is an aggressive screening protocol justified?

The incidence and sequelae of deep venous thrombosis (DVT) in trauma patients are unclear because the majority of patients who develop DVT are asymptomatic. This study evaluated the incidence, risk factors, and efficacy of prophylaxis for DVT in trauma patients over a 5-year period. Trauma patients at high risk for DVT were evaluated biweekly with lower extremity venous duplex scans. The DVT prophylaxis was instituted on admission with low-dose heparin therapy and pneumatic compression. The incidence of asymptomatic DVT identified by duplex screening was 10% (45 of 458); one pulmonary embolus occurred. Five variables were significant from bivariate and multiple logistic regression analysis: age (p = 0.005), Injury Severity Score (p = 0.005), length of stay (p = 0.004), Trauma and Injury Severity Score (p = 0.01), and spinal injury (p = 0.014). This analysis documents that trauma patients with these risk factors are at increased risk for the development of asymptomatic DVT, despite prophylaxis, and warrant surveillance with venous duplex sonography.

Safety and efficacy of intravenous Carbicarb in patients undergoing surgery: comparison with sodium bicarbonate in the treatment of mild metabolic acidosis. SPI Research Group. Study of Perioperative Ischemia.

OBJECTIVES: To compare the safety and efficacy of intravenous Carbicarb with intravenous sodium bicarbonate in well-oxygenated patients who developed metabolic acidosis while undergoing major surgery. Carbicarb is an equimolar solution of sodium bicarbonate and sodium carbonate (Na2CO3). It does not undergo significant breakdown to CO2 and H2O, nor does it increase CO2 concentrations to the same extent as does pure sodium bicarbonate. Because of these characteristics, Carbicarb may be a more suitable agent than bicarbonate in the treatment of metabolic acidosis. DESIGN: Prospective, double-blind, randomized, multicenter trial. SETTING: Veterans Affairs Medical Center (a teaching hospital of the University of California, San Francisco), and the University of Massachusetts Medical Center, Worcester, MA. PATIENTS: We prospectively studied 36 patients who underwent either cardiac surgery or major noncardiac surgery and developed intraoperative metabolic acidosis (pH < 7.35 and whose serum bicarbonate concentration decreased by > 3 mmol). INTERVENTIONS: Patients were randomly assigned to receive either sodium bicarbonate (1 mEq sodium/mL, n = 18) or 1 mol Carbicarb (1 mEq sodium/mL, n = 18) administered by intravenous bolus over a 30-sec period. MEASUREMENTS AND MAIN RESULTS: For Carbicarb-treated patients, the mean arterial pH increased from 7.31 +/- 0.008 (baseline) to 7.36 +/- 0.009 10 mins after treatment; for the sodium bicarbonate-treated patients, the mean pH increased from 7.31 +/- 0.006 to 7.37 +/- 0.01. The increases in pH were statistically significant for both groups (p = .0001). There was no statistically significant difference between treatment groups in the number of repetitions of initial dose that was required to correct acidosis. Hemodynamic variables remained unchanged in both treatment groups during the study period, with the exception of the mean cardiac output which increased from 6.1 +/- 0.4 (baseline) to 6.9 +/- 1.4 L/min (60 mins after treatment) in a subset of Carbicarb-treated patients and decreased from 6.7 +/- 1.3 to 6.0 +/- 1.2 L/min in a subset of sodium bicarbonate-treated patients, p = .048 (between groups); and the mean pulmonary artery occlusion pressure decreased from 19 +/- 2 mm Hg (baseline) to 8 +/- 3 mm Hg (45 mins after treatment) in the Carbicarb-treated patients, and decreased from 18 +/- 2 to 13 +/- 4 mm Hg in the sodium bicarbonate-treated patients, p = .012 (between groups). Systemic utilization of lactate increased from 0.3 +/- 1.0 mmol/min (baseline) to 5.6 +/- 4.3 mmol/min (45 mins after treatment) in Carbicarb-treated patients, and increased from 1.0 +/- 0.6 mmol/min (baseline) to 1.5 +/- 1.3 mmol/min in the sodium bicarbonate-treated patients, p = .033 (between groups). The administration of Carbicarb was safe. No patients were discontinued from the study because of adverse events. CONCLUSIONS: Carbicarb corrects metabolic acidosis as well as sodium bicarbonate. However, the potential therapeutic advantage of Carbicarb remains to be determined, especially in patients with more severe metabolic acidosis.

Analgesic effect of intraarticular bupivacaine or morphine after arthroscopic knee surgery: a randomized, prospective, double-blind study.

The effect of 20 mL of intraarticular bupivacaine (0.25%, with or without 1:200,000 epinephrine), morphine (0.03%, with or without 1:200,000 epinephrine), or normal saline on postoperative analgesia after arthroscopic knee surgery was studied in a randomized, prospective, double-blind trial in ASA I-III outpatients receiving general anesthesia (n = 112) or regional anesthesia (n = 27 [spinal (n = 25) or epidural (n = 2)]). The visual analogue pain scores in the postanesthesia care unit and 3, 6, 12, and 24 h after surgery, time to first analgesic use, and total 24-h analgesic requirements were recorded. In those who received general anesthesia, the visual analogue scores were significantly lower in the bupivacaine group compared with both the morphine- and placebo-treated patients (P less than 0.05). The time to first analgesic use was longer in both the bupivacaine and morphine groups when compared with the control group (P less than 0.05). No significant differences were detected in total 24-h analgesic requirements among the groups. Patients who had received regional anesthesia had lower visual analogue scores compared with patients who had received general anesthesia irrespective of the intraarticular treatment (P less than 0.05). Our results indicate that intraarticular injection of bupivacaine after arthroscopic knee surgery provides prolonged analgesia but that there is no significant prolonged analgesia provided by intraarticular morphine.

Tumor necrosis factor-alpha causes myocardial depression in guinea pigs.

BACKGROUND AND METHODS: Tumor necrosis factor-alpha (TNF-alpha) is an important mediator of metabolic and cardiovascular derangements in sepsis and endotoxicosis. We tested the hypothesis that TNF-alpha causes myocardial depression and alters the cardiac responsiveness to administered norepinephrine. Albino Hartley guinea pigs (n = 32) of either sex were injected iv with saline (1.5 mL) or recombinant human TNF-alpha (1 mg/kg). At 6, 24, or 72 hrs after injection, atria were harvested, split, connected to force displacement x transducer-amplifier-recorder systems and maintained in vitro in oxygenated 37.5 degrees C Krebs-Henseleit buffer. RESULTS: Maximal left atrial force of contraction and maximal left atrial velocity of contraction were decreased in the TNF-alpha treated animals compared with controls (p less than .05), irrespective of time after TNF-alpha injection. There were no differences between groups for left atrial maximal velocity of relaxation and right atrial rate. The norepinephrine concentration that elicited a 50% maximal left atrial contractile response (ED50) was higher in TNF-alpha treated animals compared with controls (p less than .05). Maximal left atrial force of contraction, maximal right atrial rate, and right atrial ED50 were similar in the two groups. CONCLUSIONS: These results indicate that TNF-alpha injected in vivo causes in vitro myocardial depression and alters cardiac responsiveness to norepinephrine.

Gastric tonometry and venous oximetry in cardiac surgery patients.

OBJECTIVE: To determine the relationship between gastric intramucosal pH and several other indices of splanchnic perfusion in patients undergoing cardiopulmonary bypass. DESIGN: Prospective, single-arm study. SETTING: University Hospital. METHODS: Elective cardiac surgery patients (n = 8), free of hepatic disease, were studied. Before anesthetic induction, a triple-lumen, heparin-bonded fiberoptic catheter was inserted into the hepatic vein under fluoroscopic guidance. An identical catheter was inserted into the pulmonary artery. After endotracheal intubation, a nasogastric tube modified to permit measurement of gastric intramucosal pH was inserted into the stomach. Systemic oxygen delivery (DO2), and arterial, mixed venous, hepatic venous, and femoral venous blood gases and lactate concentrations were recorded at the following times: immediately before induction of anesthesia (time 1); during atrial cannulation (time 2); after 30 mins of hypothermic cardiopulmonary bypass (time 3); 15 mins after termination of cardiopulmonary bypass (time 4); and 1 hr after arrival in the ICU (time 5). Hepatic venous hemoglobin saturation (SO2) and mixed venous hemoglobin saturation (SvO2) were monitored continuously from times 1 to 5. Gastric intramucosal pH was recorded at times 2, 3, 4, and 5. The hepatic catheter was removed as soon as the last samples were collected in the ICU. RESULTS: The square of the weighted mean correlation coefficients (rw)2 for gastric intramucosal pH vs. hepatic venous lactate concentrations, gastric intramucosal pH vs. hepatic venous PO2, and gastric intramucosal pH vs. hepatic venous pH were (rw)2 = .50, (rw)2 = .58, and (rw)2 = .32, respectively. Systemic DO2, hepatic venous lactate concentrations, hepatic venous PO2, and hepatic venous pH were significant determinants in the multiple regression model for gastric intramucosal pH (r2 = .89). There were significant differences between SvO2 and hepatic venous SO2 at times 4 and 5. CONCLUSION: Gastric intramucosal pH may provide a minimally invasive way to monitor the adequacy of splanchnic DO2 in patients undergoing cardiopulmonary bypass. Additional data are necessary to determine whether low gastric intramucosal pH is truly a marker of supply-dependent oxygen uptake across the hepatosplanchnic vascular bed under these conditions.

Free and total lidocaine levels in cardiac surgical patients.

A lidocaine bolus of 2 mg/kg has been shown to decrease the incidence of ventricular fibrillation in cardiac surgical patients during reperfusion following aortic cross-clamp release (CCR). In an effort to extend this effect into the immediate postoperative period, many centers routinely administer a prophylactic lidocaine infusion for the first 12 to 24 hours after surgery. Sequential total serum lidocaine levels were measured over 6 hours in 28 adult cardiac surgical patients without liver, kidney, or respiratory disease, and free serum lidocaine levels were measured in 15 of these patients. In addition, pharmacokinetic data were collected and analyzed in 8 of these patients. Each patient received a lidocaine bolus of 1.5 mg/kg and an infusion at 2 mg/min immediately before CCR. Serum levels were determined just before CCR, and at 10, 20, 30, 60, 120, 240, and 480 minutes after CCR. More than 50% of patients had subtherapeutic total serum lidocaine levels from 20 to 120 minutes after CCR, but free lidocaine levels remained within the therapeutic range. No patient showed malignant ventricular dysrhythmias during the study. The results suggest that (1) it may be misleading to estimate free lidocaine concentration based on total lidocaine levels; and (2) free drug is the moiety responsible for lidocaine's antiarrhythmic effect.

Total lung lavage for pulmonary alveolar proteinosis in an infant without the use of cardiopulmonary bypass.

Pulmonary alveolar proteinosis is a rare disease that usually affects the adult patient, but is now being recognized as a possible cause of neonatal respiratory distress. In the adult patient, whole lung lavage, as described by Ramirez-R in 1965, is considered the most effective therapy for management of this condition. The lavage can be accomplished safely and with relative ease by using a Carlens or Robertshaw tube to isolate and lavage one lung while ventilating the other. The unavailability of a small double-lumen tube makes this procedure impossible in the pediatric age group. Therefore, whole lung lavage has been possible in only a few children in the past with the help of cardiopulmonary bypass to allow simultaneous oxygenation during the pulmonary lavage. Due to the hazards and technical difficulties of cardiopulmonary bypass, total pulmonary lavage can not be considered a practical option in the very small infant. A 15-week-old infant is reported, weighing 2 kg with a diagnosis of pulmonary alveolar proteinosis, who underwent total pulmonary lavage safely on three different occasions without employing cardiopulmonary bypass. A double-lumen Swan-Ganz catheter, introduced transbronchoscopically through the side-arm of a rigid, 3.5-mm Storz bronchoscope was used to isolate and lavage one lung while ventilation to the other lung was maintained through the bronchoscope. A Nellcor oximeter, utilized for transcutaneous monitoring, revealed satisfactory oxygen saturation during the entire pulmonary lavage. The transbronchoscopic lavage was monitored under direct vision with a video monitor, ensuring correct position of the bronchoscope and the catheter at all times.(ABSTRACT TRUNCATED AT 250 WORDS)