Catastrophic drug errors involving tranexamic acid administered during spinal anaesthesia.

We have reviewed accidental spinal administration of tranexamic acid. We performed a MEDLINE search of cases of administration of tranexamic acid during epidural or spinal anaesthesia between 1960 and 2018. No reports of epidural administration were identified. We identified 21 cases of spinal tranexamic acid administration. Life-threatening neurological and/or cardiac complications, requiring resuscitation and/or intensive care, occurred in 20 patients; 10 patients died. We used a Human Factors Analysis Classification System model to analyse any contributing factors, and the reports were also assessed using four published recommendations for the reduction in neuraxial drug error. In 20 cases, ampoule error was the cause; in the last case a spinal catheter was mistaken for an intravenous catheter. All were classified as skill-based errors. Several human factors related to organisational policy; dispensing and storage of drugs and preparation for spinal anaesthesia tasks were present. All errors could have been prevented by implementing the four published recommendations.

Cesarean birth - What's in a name?

BACKGROUND: Cesarean birth is known as both cesarean section (CS) and cesarean delivery (CD). The International Journal of Obstetric Anesthesia (IJOA) is the leading obstetric anesthesia journal, and a barometer of attitudes within the profession. The journal recently published the hundredth issue, spanning 25 years (to December 2016). It is an opportune time to examine the evolution of surgical birth terminology (CS versus CD) during that period. METHODS: We examined 1583 articles in IJOA, subdividing them into editorials, papers, review articles, debates and case reports. We searched for the terms CS, CD, neither or both; and examined the geographical origin of the articles, dividing them into "North America", Europe" and "Rest of the World". RESULTS: There has been a change in terminology from CS towards CD - mainly from the mid-2000s onwards. Cesarean delivery was predominantly used in North American publications, while CS was predominantly favoured in European publications. It is possible that some of these trends represent policies of journal reviewers, although this does not explain all geographical differences. CONCLUSION: The term CS may represent tautology as the Latin roots of "cesarean" and "section" both refer to cutting. This would suggest CD to be the preferred terminology. Cesarean delivery also aligns with other terminology, for example vaginal and forceps delivery. A consistent approach would improve clarity.

Anesthetic considerations in a parturient with Freeman-Sheldon syndrome.

Freeman-Sheldon syndrome is a rare genetic disorder characterized by malformations of the face, oral cavity and musculoskeletal system. This case report describes the anesthetic management of a parturient with Freeman-Sheldon syndrome, kyphoscoliosis and a cardiac pacemaker for a cesarean delivery and tubal ligation. With a predicted difficult airway, our team decided to provide a combined spinal-epidural anesthetic. Problems encountered included difficult intravenous access, failure to identify the subarachnoid space and patient discomfort during surgery.

Lidocaine infusion as a rescue analgesic in the perioperative setting.

In the present case series, three patients for whom regional anesthesia may have been the optimum technique for controlling postoperative pain are discussed. However, due to prevailing circumstances, regional anesthesia could not be provided. An intravenous infusion of lidocaine at 4 mg/min was administered perioperatively as an alternative 'rescue' analgesic technique. This infusion rate, based on previous extensive pharmacokinetic studies, is widely considered to be safe. Postoperative pain was lower than expected for the type of surgery. Anecdotal experience suggests that hospital length of stay may also be reduced, with both patient and economic benefits.

The significance of psammoma bodies on cervical cytology smears.

OBJECTIVE: The association between psammoma bodies on cervical smear (PBCS) and the presence of gynecological malignancy has been documented previously. The aim of this study was to determine the incidence of malignancy where psammoma bodies were detected on smear, to identify features that may be predictive of associated malignancy, and to make recommendations about management. METHODS: The databases of two large private pathology laboratories were accessed to obtain details of all patients reported to have PBCS between April 1992 and May 2000. A retrospective review was then undertaken to determine if any patients were found to have gynecological malignancies. The appearances of the background cells on the cervical smear and details of clinical management were recorded and evaluated. RESULTS: Twenty-two patients were found to have PBCS. Five patients were found to have a gynecological malignancy. These five patients were significantly older than the remaining patients. When these results were combined with all cases reported in the world literature, it became apparent that patients with coexisting malignancy were statistically significantly older than those not found to have malignancy (P < 0.0001). The cytological appearance of cells on the background smear was highly predictive of the presence or absence of malignancy. CONCLUSIONS: There is an association between PBCS and genital tract malignancy. This association is much stronger for postmenopausal women. The background cytology is highly predictive of the presence of associated malignancy. There is a strong argument that all women with psammoma bodies on cervical smear should undergo smear review, pelvic ultrasonography, hysteroscopy and biopsy, and laparoscopy to exclude the presence of a gynecological malignancy. For younger reproductive-aged women, a negative workup is reassuring.

Evaluation of a new percutaneous dilatational tracheostomy set apparatus.

Percutaneous tracheostomy is a well established technique used primarily to assist weaning from mechanical ventilation on many intensive care units. We report our experiences of a total of 36 procedures performed with the new Blue Rhino Percutaneous Tracheostomy Introducer Set developed by Ciaglia. The technique was successful in all cases and was simpler and quicker to perform than with the earlier Ciaglia percutaneous tracheostomy set. Difficulties were encountered when using Shiley tracheostomy tubes. Significant complications included one posterior wall tear and one tracheal cartilage ring fracture.

Peri-operative effect of major gastrointestinal surgery on serum magnesium.

This study investigates the changes in serum magnesium levels after major gastrointestinal surgery and evaluates if Plasma-Lyte 148 used as maintenance fluid influences these changes in the peri-operative period. Thirty patients presenting for procedures ranging from anterior rectal resection to thoraco-abdominal cardio-oesophagectomy were randomly allocated into two groups, one of which received compound sodium lactate solution as the maintenance crystalloid during the intra- and postoperative period, and the other Plasma-Lyte 148, a magnesium-containing crystalloid solution. Serum magnesium levels were measured pre-operatively, in the immediate recovery period and 24 h postoperatively. The results showed a statistically significant (p < 0.05) reduction in the magnesium levels in both groups. The reduction was less marked in the Plasma-Lyte group but this did not achieve statistical significance (p > 0.05) compared with the compound sodium lactate group.

Vasovagal asystole during spinal anaesthesia.

A patient in whom vasovagal asystole was induced by the performance of a spinal anaesthetic in the upright position is described. This illustrates the importance of routine monitoring of the electrocardiograph during regional anaesthesia. The risk of vasovagal syncope may be increased by the use of the sitting position and by the omission of anxiolytic premedication.

Recovery from anaesthesia in children.

There are no published comprehensive surveys of paediatric recovery room experience and the incidence of complications. A prospective survey was made of 16,700 consecutive admissions to the recovery room at the Royal Manchester Children's Hospital during the years 1985-1988. The incidence of respiratory complications was low, with laryngospasm 0.85%. The incidence of hypotension was higher than that in adult studies; over 50% of children recorded a decrease in blood pressure in the recovery room of more than 20%, compared to values before operation. The incidence of vomiting in the recovery room was also lower than in comparable adult studies. Certain aspects of recovery room practice changed during the 4 years of the study; these included routine oxygen administration, parents in the recovery room, and our approach to postoperative analgesia. The implications of these changes are discussed.

Effect of anaesthesia on the QT interval.

A prolonged electrocardiographic QT interval may be harmful during general anaesthesia. It may be prudent, therefore, to select anaesthetic agents which have the least effect on the QT interval. In a controlled study, propofol has been shown to have less effect on the QT interval than thiopentone (P less than 0.05). Our data suggest also that any effects which may be caused by enflurane and isoflurane are masked by the effects of the induction agent.