The use of a noninvasive positive pressure system to facilitate tracheal intubation in a difficult pediatric airway: a case report

Abstract Patients with burns to the head and neck maybe difficult to intubate or ventilate via facemask. Furthermore, post-burn scarring and microstomia may reduce the success of rescue supraglottic airway placement. While awake tracheal intubation using a flexible intubation scope is considered the optimal technique for these patients, it may not always be feasible in the pediatric population. We report a case of successful management of a difficult airway in a child with extensive post-burn head and neck deformity using a noninvasive positive pressure system to aid with inhalational induction and deep sedation during intubation using a flexible scope.

Anesthetic Implications for Patients With Implanted Hypoglossal Nerve Stimulators: A Case Report.

Obstructive sleep apnea is a serious health issue affecting more than one billion people worldwide. Although continuous positive airway pressure is the mainstay for the treatment of obstructive sleep apnea, hypoglossal nerve stimulation is a surgical option for patients who are unable to tolerate or adhere to this therapy. As more hypoglossal nerve stimulators are implanted, these patients will present with increasing frequency for medical procedures requiring general anesthesia or deep sedation. We describe our experience with one such patient and hope this information can be used to develop future guidelines to aid in the anesthetic management of these patients.

Obturator Nerve Blockade vs. Neuromuscular Blockade for the Prevention of Adductor Spasm in Patients Undergoing Transurethral Resection of Bladder Tumors: A Randomized Controlled Trial.

BACKGROUND: The obturator nerve runs along the posterolateral walls of the bladder and electrosurgical stimulation in this region can result in adductor spasm which can occur suddenly and unexpectedly with potentially catastrophic results. METHODS: Sixty patients were prospectively randomized to receive either a single-injection ultrasound-guided obturator nerve block (ONB) or intravenous rocuronium after induction of general anesthesia (i.e., neuromuscular block [NMB]). The primary objective was to compare the incidence of adductor spasm during posterolateral bladder tumor resection when ONB or NMB was used. Secondary objectives included assessment of fall risk and incidence of adverse events. RESULTS: Five patients in the ONB group and six in the NMB group had nonlateral wall lesions. One patient in the ONB group suffered a cardiac arrest after induction of general anesthesia. Of the remaining 48 patients, six (10.2%) experienced adductor spasm. Most of these patients were in the NMB group (5/24, 20.8%), with only one patient (1/24, 4.2%) experiencing obturator reflex in the ONB group; this difference was not statistically significant (P=0.19). Patients in the ONB group had a greater decrease in mean hip adductor strength. Our study population was found to be at high risk of falls before surgery. There were no statistically significant group differences in the Timed Up and Go test, with time to perform the test increasing in both groups. CONCLUSIONS: Both techniques are safe and efficacious for preventing adductor spasm. Our data and experience suggest that the ONB is relatively easy to perform and should be considered in patients with posterolateral bladder tumors.

Antifungal activity and toxicity studies of flavanones isolated from Tessaria dodoneifolia aerial parts.

Tessaria dodoneifolia [Asteraceae] is traditionally employed in Northwestern Argentina for fungal infections treatment. We report the antifungal activity guided isolation and identification of substances from aerial parts of this species, both individually and in combination with fluconazole (FLU), against Candida albicans strains. Two antifungal flavanones were identified as naringenin (NAR) and pinocembrin (PIN). These compounds could individually inhibit the growth of C. albicans strains. Combinations of NAR and PIN with FLU were synergistic against the FLU resistant and sensitive C. albicans strains. Genotoxic and cytotoxic evaluations were also performed. NAR, PIN and their combinations with FLU did not have a genotoxic effect on Bacillus subtilis rec strains. Finally, these compounds did not show cytotoxicity at concentrations below 80 µg/mL.

Novel Use of the PECS II Block in Major Vascular Surgery: A Case Report.

Patients presenting for major vascular surgery are often elderly, medically complex, and at increased risk for general anesthesia-related complications. A search of the published literature produced no citation regarding PECS II block in the setting of extra-anatomic bypass procedures. We present a case report describing the use of the deep injection of the PECS II block in this context. Although further investigation is needed to determine the role of truncal blocks in major vascular surgery, our case illustrates that peripheral nerve blocks, combined with continuous spinal anesthesia, may be used as an alternative to general anesthesia for axillofemoral-femoral bypass.

Osteopetrosis-Anesthetic Considerations for Total Knee Arthroplasty: A Case Report.

Autosomal dominant or benign osteopetrosis is a rare genetic disorder of osteoclasts that results in dense but brittle bone structures. Patients with osteopetrosis may be scheduled for total knee arthroplasty to treat painful and functionally limiting osteoarthrosis. A search of the published literature produced no citation concerning anesthesia for patients with autosomal dominant osteopetrosis undergoing total knee arthroplasty. We present a case report detailing our experience and discuss considerations for the care of future patients with autosomal dominant osteopetrosis.

Antifungal activity and cytotoxicity of extracts and triterpenoid saponins obtained from the aerial parts of Anagallis arvensis L.

ETHNOPHARMACOLOGICAL RELEVANCE: Anagallis arvensis L. (Primulaceae) is used in argentinean northwestern traditional medicine to treat fungal infections. We are reporting the isolation and identification of compounds with antifungal activity against human pathogenic yeast Candida albicans, and toxicity evaluation. AIM OF THE STUDY: to study the antifungal activity of extracts and purified compounds obtained form A. arvensis aerial parts, alone and in combinations with fluconazole (FLU), and to study the toxicity of the active compounds. MATERIALS AND METHODS: Disk diffusion assays were used to perform an activity-guided isolation of antifungal compounds from the aerial parts of A. arvensis. Broth dilution checkerboard and viable cell count assays were employed to determine the effects of samples and combinations of FLU + samples against Candida albicans. The chemical structures of active compounds were elucidated by spectroscopic analysis. Genotoxic and haemolytic effects of the isolated compounds were determined. RESULTS: Four triterpenoid saponins (1-4) were identified. Anagallisin C (AnC), exerted the highest inhibitory activity among the assayed compounds against C. albicans reference strain (ATCC 10231), with MIC-0 =1µg/mL. The Fractional Inhibitory Concentration Index (FICI=0.129) indicated a synergistic effect between AnC (0.125µg/mL) and FLU (0.031µg/mL) against C. albicans ATCC 10231. AnC inhibited C. albicans 12-99 FLU resistant strain (MIC-0 =1µg/mL), and the FICI=0.188 indicated a synergistic effect between AnC (0.125µg/mL) and fluconazole (16µg/mL). The combination AnC+ FLU exerted fungicidal activity against both C. albicans strains. AnC exerted inhibitory activity against C. albicans ATCC 10231 sessile cells (MIC50=0.5µg/mL and MIC80=1µg/mL) and against C. albicans 12-99 sessile cells (MIC50=0.75µg/mL and MIC80=1.25µg/mL). AnC exerted haemolytic effect against human red blood cells at 15µg/mL and did not exerted genotoxic effect on Bacillus subtilis rec strains. CONCLUSIONS: The antifungal activity and lack of genotoxic effects of AnC give support to the traditional use of A. arvensis as antifungal and makes AnC a compound of interest to expand the available antifungal drugs.

Perineural Liposomal Bupivacaine for Postoperative Pain Control in Patients Undergoing Upper Extremity Orthopedic Surgery: A Prospective and Randomized Pilot Study.

BACKGROUND: Upper extremity surgery is commonly performed in the ambulatory setting and is associated with moderate to severe postoperative pain. METHODS: Patients scheduled for upper extremity orthopedic surgery with a peripheral nerve block were randomized to receive either an ultrasound-guided single-injection supraclavicular block or ultrasound-guided median, ulnar, and radial nerve blocks (forearm blocks) performed at the level of the mid to proximal forearm with liposomal bupivacaine (Exparel) combined with a short-acting supraclavicular block. A sham block was performed in an attempt to blind enrollees in the control group. We administered the EuroQol 5D-5L questionnaire preoperatively and on postoperative days 1-3 and considered the results the primary outcome of our investigation. Block procedure times, postanesthesia care unit (PACU) length of stay, instances of nausea/vomiting, need for narcotic administration, and patient satisfaction were also assessed. RESULTS: We observed no significant differences in postoperative EuroQol scores between the 2 groups and no significant differences in patient demographics, PACU length of stay, or side effects in the PACU. In some instances, the short-acting supraclavicular block resolved in the PACU, and these patients reported higher pain scores and required titration of analgesics prior to discharge. CONCLUSION: Larger prospective studies are needed to determine the safety and efficacy of liposomal bupivacaine in patients undergoing upper extremity surgery. Liposomal bupivacaine is currently only approved for local anesthetic infiltration use.

Axillary Block-Induced Chemical Sympathectomy in the Setting of Digital Ischemia.

BACKGROUND: Digital ischemia is associated with several rheumatologic disorders and is often difficult to treat. Symptoms and sequelae can include pain, disability, need for amputation, and poor quality of life. METHODS: Patients diagnosed with digital ischemia were referred for an ultrasound-guided axillary nerve block using liposomal bupivacaine (Exparel, Pacira Pharmaceuticals). The primary outcome measure was radial and ulnar artery diameter preprocedure and postprocedure. Doppler waveform analyses were performed to measure arterial diameter and blood flow velocity. The QuickDASH questionnaire was administered to evaluate upper extremity function and perceived disability. RESULTS: Mean radial and ulnar artery diameters increased from 0.19 cm and 0.16 cm to 0.23 cm and 0.20 cm, respectively, 1 hour postprocedure. Concomitant increases in blood flow velocities and hand temperature and lower pain scores were also noted. Although pain generally returned to baseline after 1 week, QuickDASH symptom/disability scores improved at 30 days, and 2 patients' ischemic symptoms resolved spontaneously during the study period in the absence of other interventions. CONCLUSION: Data regarding chemical sympathectomy using regional anesthesia are limited at this time. Our experience suggests a potential role in the treatment and evaluation of digital ischemia. Patients with digital ischemia from rheumatologic conditions appeared to have a greater benefit from a chemical sympathectomy than patients whose conditions had an atherosclerotic or anatomic etiology. Even when the vasodilatory effects are transient, such an intervention may be useful when a more permanent option such as surgical sympathectomy is being considered. Liposomal bupivacaine is only approved for surgical infiltration at this time.

Distal Peripheral Nerve Blocks in the Forearm as an Alternative to Proximal Brachial Plexus Blockade in Patients Undergoing Hand Surgery: A Prospective and Randomized Pilot Study.

PURPOSE: Limited data exist regarding the role of perineural blockade of the distal median, ulnar, and radial nerves as a primary anesthetic in patients undergoing hand surgery. We conducted a prospective and randomized pilot study to compare these techniques to brachial plexus blocks as a primary anesthetic in this patient population. METHODS: Sixty patients scheduled for hand surgery were randomized to receive either an ultrasound-guided supraclavicular, infraclavicular, or axillary nerve block (brachial plexus blocks) or ultrasound-guided median, ulnar, and radial nerve blocks performed at the level of the mid to proximal forearm (forearm blocks). The ability to undergo surgery without analgesic or local anesthetic supplementation was the primary outcome. Block procedure times, postanesthesia care unit length of stay, instances of nausea/vomiting, and need for narcotic administration were also assessed. RESULTS: The 2 groups were similar in terms of the need for conversion to general anesthesia or analgesic or local anesthetic supplementation, with only 1 patient in the forearm block group and 2 in the brachial plexus block group requiring local anesthetic supplementation or conversion to general anesthesia. Similar durations in surgical and tourniquet times were also observed. Both groups reported similarly low numerical rating scale pain scores as well as the need for postoperative analgesic administration (2 patients in the forearm block group and 1 in the brachial plexus block group reported numerical rating scale pain scores > 0 and required opioid administration in the postanesthesia care unit). Block procedure characteristics were similar between the 2 groups. CONCLUSIONS: Forearm blocks may be used as a primary anesthetic in patients undergoing hand surgery. Further research is warranted to determine the appropriateness of these techniques in patients undergoing surgery in the thumb or proximal to the hand. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Ultrasound-guided popliteal sciatic nerve blockade in the severely and morbidly obese: a prospective and randomized study.

PURPOSE: Limited research data exist regarding optimal block techniques in the severely and morbidly obese patient population. We compared two approaches to sciatic nerve blockade at the popliteal fossa in severely and morbidly obese patients. The purpose of this study was to identify differences in pain scores, block onset characteristics, and adverse events between the proximal (prebifurcation) and the distal (postbifurcation) sites. METHODS: Patients with a body mass index ≥35 scheduled for unilateral foot surgery with a popliteal block were randomized to receive an ultrasound-guided popliteal block proximal or distal to the bifurcation of the sciatic nerve. The primary endpoint was numerical rating scale (NRS) scores in the post anesthesia care unit (PACU). RESULTS: Thirty patients were enrolled in each group for a total of 60 participants. Patients in the distal group had lower NRS scores upon entry into the PACU (0.70 ± 1.91) compared with the proximal group (2.17 ± 3.37), had a faster onset of sensorimotor blockade, and were less likely to require a repeat block procedure, conversion to general anesthesia, or local anesthetic supplementation by the surgical team. There was no difference in block procedure times or incidence of nerve injury between the two groups. CONCLUSIONS: The distal approach to the popliteal block provided several intraoperative and analgesic benefits without a difference in block procedural times in the severely and morbidly obese. It is a cost-free intervention that results in a higher likelihood of a successful block in a population where avoidance of opioids is desirable.

Intermediate-term follow-up of chronically ill patients with digital ischemia treated with peripheral digital sympathectomy.

Digital ischemia is commonly found in patients with scleroderma and has been shown to respond to peripheral digital sympathectomy. While favorable long- and intermediate-term results have been documented in the literature, minimal objective data are available and the mechanism of surgical sympathectomy has not been entirely elucidated. Patients with digital ischemia secondary to Raynaud's phenomenon that had undergone peripheral sympathectomy surgery between 2001 and 2009 were identified and contacted for participation. Radial artery Doppler ultrasound studies were performed and compared to those done at the time of their sympathectomy. Of 11 patients treated over a 9-year period, only two patients were available for detailed follow-up analysis. Four patients were deceased, and two were lost to follow-up. Four of the five remaining patients reported excellent use of the hand and no significant episodes of digital ischemia. Of the two patients studied, functional results were favorable and pain was markedly improved despite worsening of the digital flow resistance over time. We conclude that peripheral digital sympathectomy may provide favorable long-term results in patients with digital ischemia from autoimmune causes, although this intervention should be considered in the early stages once ischemic symptoms manifest. Interestingly, Doppler data did not appear to correlate with functional status and symptom severity in these two patients. Further research, particularly prospective studies, is warranted to guide clinical decisions in this patient population.

Antifungal activity of 4-hydroxy-3-(3-methyl-2-butenyl)acetophenone against Candida albicans: evidence for the antifungal mode of action.

The main secondary metabolite of Senecio nutans is 4-hydroxy-3-(3-methyl-2-butenyl)acetophenone (4HMBA). The antifungal activity of this compound and three derivatives was assessed using Candida albicans. 4HMBA exhibited the highest antifungal activity among the assayed compounds. The Fractional Inhibitory Concentration (FIC = 0.133) indicated a synergistic fungicidal effect of 4HMBA (5 mg L(-1)) and fluconazole (FLU) (0.5 mg L(-1)) against the C. albicans reference strain (ATCC 10231). Microscopy showed that 4HMBA inhibits filamentation and reduces cell wall thickness. Our findings suggest that 4HMBA is an interesting compound to diminish resistance to commercial fungistatic drugs such as fluconazole.

Distal peripheral nerve blockade for patients undergoing hand surgery: a pilot study.

BACKGROUND: Data are limited regarding the use of peripheral nerve blockade at the level of the forearm, and most studies regard these procedures as rescue techniques for failed or incomplete blocks. The purpose of the study was to investigate patients undergoing hand surgery with distal peripheral nerve (forearm) blocks and compare them with patients having similar procedures under more proximal brachial plexus blockade. No investigations comparing distal nerve blockade to proximal approaches are currently reported in the literature. METHODS: Medical records were retrospectively reviewed for patients who had undergone hand surgery with a peripheral nerve block between November 2012 and October 2013. The primary outcome was the ability to provide a primary anesthetic without the need for general anesthesia or local anesthetic supplementation by the surgical team. Secondary outcome measures included narcotic administration during the block and intraoperative procedures, block performance times, and the need for rescue analgesics in the post anesthesia care unit (PACU). RESULTS: No statistical difference in conversion rates to general anesthesia was observed between the two groups. Total opiate administration for the block and surgical procedure was lower in the forearm block group. There was no difference in block performance times or need for rescue analgesics in the PACU. CONCLUSIONS: Forearm blocks are viable alternatives to proximal blockade and are effective as a primary anesthetic technique in patients undergoing hand surgery. Compared to the more proximal approaches, these blocks have the benefits of not causing respiratory compromise, the ability to be performed bilaterally, and may be safer in anticoagulated patients.

The adductor canal block provides effective analgesia similar to a femoral nerve block in patients undergoing total knee arthroplasty--a retrospective study.

STUDY OBJECTIVE: To determine the ability of an ultrasound-guided single-shot adductor canal block to provide adequate analgesia and improve performance during physical therapy. DESIGN: A retrospective chart review. SETTING: All procedures were performed at Ochsner Medical Center. MEASUREMENTS: Patient demographics as well as the type of peripheral nerve block performed. Pain scores and opioid consumption were recorded at postanesthesia care unit discharge and again at 8 ± 3, 16 ± 3, and 24 ± 3 hours. In addition, physical therapy performance was analyzed. MAIN RESULTS: There were no significant differences in pain scores or cumulative hydromorphone requirements between the adductor canal block group and the femoral nerve block group at any of the time points analyzed. Gait distance measured during physical therapy sessions in the adductor canal block group was superior compared with the femoral nerve block group. CONCLUSION: Within the first 24 hours, a single-shot adductor canal block provides equally effective analgesia when compared with a femoral nerve block and improves postoperative physical therapy performance.

Isolation, identification and usefulness of antifungal compounds from Zuccagnia punctata for control of toxigenic ear rot pathogens.

Infusion, tincture and decoction of leaves of Zuccagnia punctata Cav. were assayed on growth of Fusarium verticillioides, F. graminearum sensu stricto, F. boothii, F. meridionale, F. subglutinans and F. thapsinum. The tincture showed the lowest IC50 on mycelial growth. A diethyl ether fraction of the tincture showed the highest antifungal activity in microdilution assays on F. verticillioides and F. graminearum. The antifungal constituents were separated by silica gel chromatography and identified as 2',4'-dihydroxychalcone, 2',4'-dihydroxy-3'-methoxychalcone and 7-hydroxy-3',4'-dimethoxyflavone. These chalcones had the lowest MIC and MFC values on F. verticillioides and F. graminearum sensu stricto. 2',4'-Dihydroxychalcone was mildly toxic and the remaining identified compounds were non-toxic in the brine shrimp assay. 2',4'-Dihydroxychalcone in mixtures with commercial food preservatives showed additive effects on F. graminearum sensu stricto and synergistic ones on F. verticillioides. 2',4'-Dihydroxy-3'-methoxychalcone showed synergistic effects in mixtures. Our results suggest that addition of chalcones to food preservatives allows reduction in the doses of the preservatives required for control of Fusarium species.

Antibacterial activities of Ligaria cuneifolia and Jodina rhombifolia leaf extracts against phytopathogenic and clinical bacteria.

Six plant extracts prepared from Ligaria cuneifolia and Jodina rhombifolia were screened for their potential antimicrobial activities against phytopathogens and clinically standard reference bacterial strains. Bioautography and broth microdilution methods were used to study samples antibacterial activities against 7 bacterial strains. The minimum inhibitory concentrations (MICs) and minimum bactericidal concentrations (MBCs) of samples were attained. An antibacterial activity guided isolation and identification of active compounds was carried out for L. cuneifolia methanolic extract (LCME). Both methanolic and aqueous extracts from L. cuneifolia showed inhibitory activities against phytopathogenic bacteria, with MICs ranging from 2.5 to 156 µg mL(-1) for LCME and 5 mg mL(-1) for the aqueous extract. None of the three J. rhombifolia extracts showed significant antibacterial activities against phytopathogenic strains (MIC > 5 mg mL(-1)), except for the aqueous extracts against Pseudomonas syringae (MIC = 312 µg mL(-1)). Only LCME showed bactericidal activities against phytopathogenic strains (MBCs = 78 µg mL(-1)). The LCME exhibited significant inhibitory activity against reference clinical strains: Escherichia coli (MIC = 156 µg mL(-1)) and Staphylococcus aureus (MIC = 78 µg mL(-1), MBC = 312 µg mL(-1)). LCME active compounds were identified as flavonol mono and diglycosides, and gallic acid. The antibacterial activity of purified compounds was also evaluated. A synergistic effect against S. aureus was found between gallic acid and a quercetin glycoside. Hence, anti-phytopathogenic bacteria potential compounds isolated from L. cuneifolia could be used as an effective source against bacterial diseases in plants.