Posterior reversible encephalopathy syndrome: a report of a case with atypical features.

We report a case of a young woman presenting with profound depression of consciousness and intra-uterine death in the late stages of an unbooked pregnancy. She proceeded to develop features of cardiovascular, renal, hepatic and haematological failures. The patient was challenging to manage in view of uncertainty regarding the underlying cause, and required multidisciplinary consultation. A diagnosis was subsequently made of posterior reversible encephalopathy syndrome in the context of pre-eclampsia. We review the typical presentation and wide-ranging associations of this recently described clinico-neuroradiological syndrome, and look at how appropriate management may lead to rapid resolution of its often life-threatening features. We highlight the importance to anaesthetists and critical care physicians of recognising even atypical cases such as this one in view of key differences in management from similarly presenting conditions.

A descriptive study of the variation in baseline levels of antiendotoxin core antibodies between US and UK populations.

Low levels of naturally occurring antibodies to the core section of endotoxin (EndoCAb) have been shown to be predictors of poor outcome following major surgery. We performed a retrospective study comparing pre-operative levels in US surgical patients, UK surgical patients and healthy volunteers. Both IgM and IgG EndoCAb levels were higher in the US surgical patients when compared with the other groups (approximately twice as high in the case of IgG EndoCAb). This may reflect genetic or environmental variability between the patient groups, differences in the disease processes, the disparity in the delivery of health care between the two countries or degradation of the samples in transfer.

Assessment of preoperative fluid depletion using bioimpedance analysis.

BACKGROUND: Fluid depletion during the perioperative period is associated with poorer outcome. Non-invasive measurement of total body water by bioimpedance may enable preoperative fluid depletion and its influence on perioperative outcome to be assessed. METHODS: Weight and foot bioimpedance were recorded under standardized conditions in patients undergoing bowel preparation (n=43) or day surgery (n=44). Fifteen volunteers also followed standard nil-by-mouth instructions on two separate occasions to assess the variabilities of weight and bioimpedance over time. RESULTS: Body weight fell by 1.27 kg (95% CI 1.03-1.50 kg; P<0.0001) and foot bioimpedance increased by 51 ohm after bowel preparation (95% CI 36-66; P<0.0001). Weight change after the nil-by-mouth period in day-surgery patients (mean -0.22 kg, 95% CI -0.05 to -0.47 kg; P=0.07) correlated (r=-0.46; P=0.005) with an increase in bioimpedance (16 ohms, 95% CI 5-27 ohms; P=0.01). No difference between two separate bioimpedance measurements was seen in the volunteer group. CONCLUSIONS: Further work is warranted to determine if bioimpedance changes may serve as a useful indicator of perioperative fluid depletion.

A retrospective observational study of pre-operative sickle cell screening.

The aim of this study was to determine the ethnic mix of those patients being pre-operatively screened for sickle cell disease in a London teaching hospital and to determine the rate of carriage of sickle haemoglobin amongst those tested. We retrospectively studied 1879 patients undergoing surgery over a 2-month period. Two hundred and thirteen (11%) were screened for sickle cell disease and of these, 12 (5%) tested positive for sickle cell trait (HbAS). There were no patients homozygous for sickle cell disease (HbSS) or with haemoglobin SC disease (HbSC). Screening rates varied widely in different ethnic groups from 0% of the Chinese population to 85.2% of the Afro-Caribbean population. We conclude that at present there is no coherent pre-operative screening policy for sickle cell disease in our institution. Sickle cell disease poses unique anaesthetic risks and with a rapidly expanding 'mixed race' population high-risk patients are difficult to identify phenotypically. We propose a universal screening policy be implemented in high-risk areas.

A prospective observational study of the subjective experience of caesarean section under regional anaesthesia.

The aim of our study was to determine the subjective sensation of caesarean section under regional anaesthesia. We performed a prospective, observational study of 205 patients undergoing caesarean section under regional anaesthesia in a UK district general hospital. Patients were asked open and closed questions relating to their physical and emotional experience during the operation. Seventy-three percent of patients chose the phrase "pulling and pushing" to describe the physical sensation of the operation, 75% described the experience as pleasant, and only 4% described it as unpleasant, the rest saying it was neither pleasant nor unpleasant. Ninety-six percent said they would by choice have any future caesarean section under regional anaesthesia, 3% were undecided and 1% said they would prefer a general anaesthetic next time. This study provides important precise information that may be given to patients before caesarean section under regional anaesthesia. We believe it will help minimise preoperative fears and increase patients' ability to make informed decisions about their care.