Bone marrow harvesting using EMLA (eutectic mixture of local anaesthetics) cream, local anaesthesia and patient-controlled analgesia with alfentanil.

Bone marrow harvesting (BMH) was performed on 40 consecutive allogeneic or autologous donors using EMLA (eutectic mixture of local anaesthetics), local anaesthesia (LA) and patient-controlled analgesia with alfentanil (PCA-A). The effect of alkalinizing the LA solution on reducing pain during LA infiltration in the presence of EMLA was also investigated. EMLA 10 g with occlusive dressing was applied to the harvest sites at least 60 min before BMH. The PCA device was programmed to deliver an intravenous loading dose of 15 microg/kg alfentanil, followed by a background alfentanil infusion of 0.05 microg/kg/min. Demand dose was 4 microg/kg and lockout time was 3 min. Donors were randomized to receive either alkalinized (n = 19) or non-alkalinized (n=21) LA solution (lignocaine 1% with 1:100000 adrenaline). While post-operative nausea and vomiting were the only side-effects, all donors in both groups reported satisfactory pain scores during LA infiltration and satisfactory overall intra-operative comfort scores. They completed BMH using either regimen successfully, found this technique acceptable and would recommend this form of anaesthesia to others. Alkalinizing the LA solution did not significantly improve the pain scores during LA infiltration in the presence of EMLA. In conclusion, BMH can be performed safely using EMLA, LA and PCA-A without major complications.

Two case reports of intracranial teratoma diagnosed antenatally.

Two cases of foetal intracranial teratoma, diagnosed by antenatal ultrasound, are described. One is a mature teratoma while the other an immature form. The first case presented as epignathus with extracranial extension. Very few cases of fetal intracranial teratoma have been reported. These are uniformly fatal. A review of reported cases indicates that prenatal intracranial teratoma can be accurately diagnosed. Prenatal diagnosis would allow for multidisciplinary team approach and planned delivery in a tertiary care centre.

The effect of a pain management program on patients with cancer pain.

BACKGROUND: Pain is 1 of the most common symptoms that a cancer patient would experience. A significant barrier to positive pain management is patients' misconceptions regarding analgesics and inadequate use of nonpharmacological strategies as pain relief. OBJECTIVE: The purpose of this study was to investigate the effectiveness of a pain management program (PMP) on pain intensity, use of PRN drugs and nonpharmacological strategies as pain relief, and barriers to managing pain in cancer patients. METHODS: The study was conducted in the palliative care and hospice ward of a public hospital in Hong Kong. Patients were randomized to either an experimental group (receiving the PMP) or a control group (routine care). There were 38 hospitalized patients, with 20 (13 males and 7 females) in the experimental group and 18 (11 males and 7 females) in the control group; mean age was 61.95 years (experimental group) to 63.94 years (control group). RESULTS: Upon the completion of PMP, pain scores were significantly reduced in both groups, yet patients in the experimental group showed a significant increase in the use of PRN analgesics and nonpharmacological strategies to relieve pain (P < .05) and significantly reduce barriers to managing their cancer pain (P < .05) compared with the control group. CONCLUSION: Cancer patients should be empowered with pain management education to gain knowledge and correct misconceptions in managing their cancer pain. IMPLICATIONS FOR PRACTICE: Integration of the PMP into routine clinical work may help to improve the standard of care for cancer patients. It is recommended to provide pain management education to all cancer patients.

Differential presentation of post tracheostomy bleeding: a case series.

The relief of upper airway obstruction is one of the indications for tracheostomy. However, this procedure is not without its complications. We present a case series where post tracheostomy bleeding results in life-threatening sequelae in the form of torrential haemorrhage and sudden airway obstruction from clot. The latter presentation can present a diagnostic conundrum that could prove fatal if not rapidly identified.

MARS therapy in critically ill patients with advanced malignancy: a clinical and technical report.

BACKGROUND/METHODS: Molecular Adsorbent Recirculating System (MARS) was used in three consecutive critically ill patients at the Singapore General Hospital with advanced malignancy and acute liver failure (ALF). Case 1 was a male patient with hepatocellular carcinoma (HCC) for which initial right hepatectomy was followed by left hepatectomy 5 months later for recurrent HCC. The postoperative course following second surgery was complicated by severe methicillin-resistant Staphylococcus aureus (MRSA) sepsis, mild azotaemia and subacute cholestatic liver failure. MARS was used thrice in this patient. Case 2 was a female patient with advanced acute lymphoblastic leukaemia (ALL) with post bone marrow transplantation (BMT) acute haemolytic-uraemic syndrome (HUS) secondary to cyclosporin A (Cy A), cytomegalovirus (CMV) infection, severe nosocomial pneumonia, acute renal failure (ARF) treated with continuous haemofiltration and acute veno-occlusive disease resulting in Budd-Chiari syndrome. The latter precipitated ALF. MARS was instituted twice. Case 3 was a male patient with advanced, refractory Hodgkin's disease previously treated with multiple courses of chemotherapy. ALF developed secondary to acute viral hepatitis B flare. He was given a trial of MARS once in the ICU. All the three patients eventually died. RESULTS: Mean MARS intradialytic systemic pressures were as follows: systolic pressure range was 95 +/- 17 to 128 +/- 17 mmHg and diastolic pressure range was 51 +/- 5 to 67 +/- 7 mmHg. Pressure at albumin dialysate exit point from dialyser 1 (Ae) ranged from 253 +/- 11 to 339 +/- 15 mmHg and that at albumin dialysate entry point into dialyser 1 (Aa) ranged from 142 +/- 11 to 210 +/- 6 mmHg. Ultrafiltration (UF) was 633 +/- 622 mL over mean treatment duration of 6.3 +/- 0.9 h with a total heparin dose of 1583 +/- 817 IU. Coagulation status pre- and 6-h post-MARS was similar: aPTT (P=0.116) and platelet count (P=0.753). There were no bleeding complications or circuit thromboses. MARS had a significant de-uraemization effect (pre- and post-MARS serum creatinine and urea: P=0.046 and 0.028, respectively) but did not significantly attenuate blood lactate, ammonia or total bilirubin levels. Albumin dialysate (Ae - Aa) urea and creatinine concentrations appeared to be sharply attenuated after 6 h of MARS. In contrast, the removal of total bilirubin by albumin dialysate from the blood compartment appeared to plateau after 4 h of continuous MARS operation. CONCLUSIONS: MARS was well-tolerated in critically ill patients with advanced and complicated cancer. Low-dose heparin was safe and did not compromise MARS circuit integrity. Although MARS had a significant de-uraemization effect, this appeared to be limited by the duration of MARS operation. Our data suggested that such a limit was reached earlier for total bilirubin. More data are needed to confirm the present findings and further delineate the saturation limit of MARS for different toxins that accumulate in ALF. This would affect the optimal duration of MARS therapy.