Perioperative considerations in patients with Gitelman syndrome: a case series.

STUDY OBJECTIVE: To determine the perioperative considerations for low-risk and high-risk surgery in patients with Gitelman syndrome. DESIGN: Retrospective chart review. SETTING: University-affiliated medical center. PATIENTS: 42 patients with Gitelman syndrome. MEASUREMENTS: Of the 42 patients with Gitelman syndrome, 5 underwent procedures requiring anesthesia: mastectomy, spinal fusion, thyroidectomy, tonsillectomy, and bronchoscopy. The anesthesia record and all associated laboratory tests and clinical notes associated with those procedures were recorded. MAIN RESULTS: No acute electrolyte abnormalities or postoperative complications occurred with these procedures in patients with Gitelman syndrome. CONCLUSION: Gitelman syndrome is a mild disorder when appropriately managed.

Hysteroscopic sterilization in women with severe cardiac disease: experience at a tertiary center.

OBJECTIVE: To determine the feasibility and effectiveness of hysteroscopic sterilization as a minimally invasive sterilization method for women with high-risk cardiac disease. PARTICIPANTS AND METHODS: In a retrospective cohort study, 18 women with high-risk cardiac conditions that strictly contraindicated pregnancy were compared with a reference cohort of 157 women without cardiac disease. All underwent microinsert hysteroscopic sterilization at Mayo Clinic from January 2003 through February 2007. End points included successful placement, fallopian tube patency determined by hysterosalpingogram 3 months after the procedure, and pregnancy status. RESULTS: Women in the cardiac cohort were younger than those in the reference cohort (median age, 25 vs 39 years; P<.001), had lower parity (median, 0 vs 2; P<.001), and had a higher proportion of patients categorized as American Society of Anesthesiologists' physical status 3 (severe systemic disease) and physical status 4 (systemic disease that is a constant threat to life) (83% vs 6%; P<.001). No significant differences were noted for use of general anesthesia (17% vs 27%; P=.41), successful bilateral device placement (100% vs 95%; P>.99), postoperative pain score (median, 0 for both groups; P=.87), or length of hospitalization (median, 6 vs 6 hours; P=.63). No intraoperative complications occurred. Follow-up hysterosalpingography showed high tubal occlusion rates in both cohorts (100% cardiac; 98% reference; P>.99). No pregnancies occurred during a median follow-up period of 20 months (interquartile range, 8-33 months). CONCLUSION: For women with cardiac disease and strict contraindications for pregnancy, microinsert hysteroscopic sterilization provided minimally invasive, permanent, and reliable contraception.

Management of the difficult and failed airway in obstetric anesthesia.

Difficulty with airway management in obstetric patients occurs infrequently and failure to secure an airway is rare. A failed airway may result in severe physical and emotional morbidity and possibly death to the mother and baby. Additionally, the family, along with the medical and nursing staff, may face emotional and financial trauma. With the increase in the number of cesarean sections performed under regional anesthesia, the experience and training in performing endotracheal intubations in obstetric anesthesia has decreased. This article reviews the management of the difficult and failed airway in obstetric anesthesia. Underpinning this important topic is the difference between the nonpregnant and pregnant state. Obstetric anatomy and physiology, endotracheal intubation in the obstetric patient, and modifications to the difficult airway algorithms required for obstetric patients will be discussed. We emphasize that decisions regarding airway management must consider the urgency of delivery of the baby. Finally, the need for specific equipment in the obstetric difficult and failed airway is discussed. Worldwide maternal mortality reflects the health of a nation. However, one could also claim that, particularly in Western countries, maternal mortality may reflect the health of the specialty of anesthesia.

Maternal and transplacental pharmacokinetics of azithromycin.

OBJECTIVE: The purpose of this study was to characterize the pharmacokinetics of orally administered azithromycin in the term gravid woman. STUDY DESIGN: Twenty women who were scheduled for elective cesarean delivery were enrolled prospectively and received 1 g of oral azithromycin at either 6, 12, 24, 72, or 168 hours before the operation. All women received spinal anesthesia, at which time a sample of cerebrospinal fluid was obtained for analysis. Maternal serum and urine were obtained immediately before the operation. Intraoperatively, samples of myometrium, maternal adipose tissue, placenta, amniotic fluid, and umbilical arterial and venous cord blood were obtained. Azithromycin levels were determined quantitatively with high-pressure liquid chromatography with electrochemical detection. RESULTS: All participants tolerated the preoperative azithromycin without significant adverse reactions. Peak maternal serum azithromycin levels occurred within 6 hours of drug administration. Although high serum levels of azithromycin were reached early, a rapid decline in drug concentration was noted over the initial 24 hours after the drug administration (6-hour: 311 ng/mL; 24-hour: 63 ng/mL). In contrast, azithromycin levels in myometrial, adipose, and placental tissue were higher (>500 ng/mL) and sustained for up to 72 hours after administration. High urine levels of azithromycin (>5000 ng/mL) were noted similarly during the initial 72 hours after drug administration. Umbilical arterial and venous serum azithromycin levels were low (19-38 ng/mL) during the first 72 hours. Amniotic fluid levels were highest at 6 hours (151 ng/mL) and declined rapidly. Maternal cerebrospinal azithromycin concentrations were undetectable for all time points. CONCLUSION: Azithromycin has a rapid serum half-life in the term gravid woman with a prolonged half-life and high-sustained antibiotic levels noted within myometrium, adipose, and placental tissue. Given the broad antimicrobial spectrum and placental penetration, azithromycin may have potential use for the treatment of perinatal infections.

Fast track anesthesia for liver transplantation reduces postoperative ventilation time but not intensive care unit stay.

Fast tracking is an approach to health care delivery that emphasizes the efficient use of resources. This investigation was designed to determine whether shorter-acting drugs and different drug administration practices reduce the length of time for which patients require mechanical ventilation and intensive care after liver transplantation. After obtaining Institutional Review Board approval and informed consent, we randomized 80 consecutive patients (>17 years) undergoing liver transplantation to receive either our traditional anesthetic (thiopental, pancuronium, 50 microg/kg fentanyl), or fast track anesthetic (propofol, cisatracurium, 20 microg/kg fentanyl). The patients were weaned to extubation in the intensive care unit after an established clinical protocol. Measured data included the occurrence of intraoperative hypotension, intraoperative hypertension, intraoperative tachycardia, the length of postoperative mechanical ventilation, length of intensive care unit stay, and episodes of reintubation. Seventy-eight patients remained in the study through the investigation (two died intraoperatively). Operating time; amount of intraoperative red blood cells transfused; lowest body temperature achieved; and minutes of intraoperative hypotension, hypertension, and tachycardia were not different between the traditional and fast track patient groups. Postoperative ventilation time was greater in the patients who received the traditional anesthetic; mean. 1,081 minutes (median, 855) versus mean, 553.5 minutes (median, 390) (P <.001). However, there was no difference in length of intensive care unit stay. Five patients required reintubation (two patients given the traditional anesthetic, three given the fast track anesthetic). We conclude that a fast track approach to anesthetic care reduces the requirement for postoperative mechanical ventilation, but does not reduce intensive care unit stay after liver transplantation.