Ultrasound-guided internal jugular venous cannulation: an introduction for non-radiologists to a technique that is here to stay.

The availability of relatively low-cost, portable ultrasound units has increased interest among non-radiologists in performing image-guided central venous cannulation, especially in high-risk patients. The essential elements of this relatively simple method of increasing the success and safety of internal jugular cannulation are presented.

Injection of the facetectomy remnant in the evaluation and treatment of postsurgical back pain: case reports.

A pain syndrome encountered in patients who have undergone laminectomy with medial facetectomy is described. The patients share the following features: (a) unilateral pain, made worse by walking and standing; (b) pain in buttock, thigh, or calf; (c) normal neurologic examination; and (d) response to injection of local anesthetic/depot steroid in the area of the resected medial facet. We believe this pain is caused by neural entrapment, and thus is worsened by movement of the spinal elements. It is proposed that these facet-remnant injections might be used to identify patients who are candidates for surgical stabilization, although this supposition will require further clinical work.

Steroid celiac plexus block for chronic pancreatitis: results in 16 cases.

Sixteen cases in which celiac plexus block with depot steroid was used to treat chronic pancreatitis pain were reviewed. Only 4 of 16 patients reported pain relief with the procedure. Of the 12 patients who did not obtain relief, narcotic dependence was present in 11 of 12. No patients in the "relief" group were narcotic dependent. Prior pancreatic surgery was present in 9 of the 12 patients without relief and in 1 of 4 patients with relief. It is postulated that refractory chronic pancreatitis pain may be an extreme form of what has been termed "abnormal illness behavior." Furthermore, these results underscore the poor results experienced using neural blockade for the relief of chronic pain when narcotic dependence is present.

Epidural morphine delivered by a percutaneous epidural catheter for outpatient treatment of cancer pain.

Twenty-three outpatients with cancer pain refractory to other methods of pain control were treated with epidural morphine (EM) delivered through a chronically placed percutaneous lumbar epidural catheter. Patients and their families were taught to administer EM at home. Mean EM doses ranged from 18 to 31 mg/day. Mean catheter lifespan was 6.3 weeks. There were no catheter-related infections or cases of respiratory depression. After 2500 patient treatment days, we have found this method to be a safe and effective method of cancer pain management in outpatients.

Heparin-induced hyperkalemia.

We have described three patients with diabetes and renal insufficiency who had hyperkalemia during heparin therapy. These cases lend support to previous findings, and emphasize the clinical importance of this entity. We believe that heparin-induced hyperkalemia is a potentially life-threatening problem that is more common than previously appreciated. We suggest that in high-risk patients (ie, those with diabetes and/or renal insufficiency) serum potassium be monitored frequently during heparin therapy.

Embolic stroke in a woman with mitral valve prolapse who used oral contraceptives.

A case of angiographically-documented embolism is presented in a patient using oral contraceptives (OC) with marked mitral valve prolapse (MVP) and an atrial thrombus. OC use has been shown to decrease levels of antithrombin III and increase platelet coagulant activity. This increased coagulability may increase the risk of intra-atrial thrombus formation and subsequent cerebral embolism in patients with MVP. We believe that MVP, especially when redundant valve leaflets are recognized, may be a relative contraindication to OC use.

PIP: A 21-year old women taking oral contraceptives suffered thromboembolic stroke associated with mitral valve prolapse. She had been using an unspecified oral contraceptive for 3 months postpartum, and had smoked a pack a day for 5 years. She complained of sudden right orbital headache, left-sided weakness and pain. Clinical exam showed left sided anopsia, facial paralysis, tongue protrusion, parietal sensory deficit, and loss of position sense. Computed tomography suggested a lesion near the right middle cerebral artery; and cerebral angiography revealed an 8 x 2 mm filling defect in that artery. A midsystolic click without a murmur was evident in the cardiac exam. Thickened, redundant mitral valve leaflets with marked prolapse, and a mass on the atrial side of the posterior leaflet appeared on the echocardiogram. The atrial thrombus was considered the source of the apparent embolism in the cerebral artery. Oral contraceptives have been found to increase the risk of thrombotic stroke and venous thromboembolism. Therefore, women with known mitral valve prolapse or leaflets may be advised not to use the pill.