No abstract

Venovenous extracorporeal membrane oxygenation (vv-ECMO) is a highly invasive method for organ support that is gaining in popularity due to recent technical advances and its successful application in the recent H1N1 epidemic. Although running a vv-ECMO program is potentially feasible for many hospitals, there are many theoretical concepts and practical issues that merit attention and require expertise. In this review, we focus on indications for vv-ECMO, components of the circuit, and management of patients on vv-ECMO. Concepts regarding oxygenation and decarboxylation and how they can be influenced are discussed. Day-to-day management, weaning, and most frequent complications are covered in light of the recent literature.

PurposeThoracic paravertebral block (TPVB) may be an alternative to thoracic epidural analgesia. A detailed knowledge of the anatomy of the TPV-space (TPVS), content and adnexa is essential in understanding the clinical consequences of TPVB. The exploration of the posterior TPVS accessibility in this study allows (1) determination of the anatomical boundaries, content and adnexa, (2) description of an ultrasound-guided spread of low and high viscous liquid.MethodsIn two formalin-fixed specimens, stratification of the several layers and the 3D-architecture of the TPVS were dissected, observed and photographed. In a third unembalmed specimen, ultrasound-guided posterolateral injections at several levels of the TPVS were performed with different fluids.ResultsTPVS communicated with all surrounding spaces including the segmental dorsal intercostal compartments (SDICs) and the prevertebral space. TPVS transitions to the SDICs were wide, whereas the SDICs showed narrowed transitions to the lateral intercostal spaces at the costal angle. Internal subdivision of the TPVS in a subendothoracic and an extra-pleural compartment by the endothoracic fascia was not observed. Caudally injected fluids spread posteriorly to the costodiaphragmatic recess, showing segmental intercostal and slight prevertebral spread.ConclusionsOur detailed anatomical study shows that TPVS is a potential space continuous with the SDICs. The separation of the TPVS in a subendothoracic and an extra-pleural compartment by the endothoracic fascia was not observed. Based on the ultrasound-guided liquid spread we conclude that the use of a more lateral approach might increase the probability of intravascular puncture or catheter position.

Chronic postsurgical pain occurs in a significant number of patients 6 months after open abdominal surgery. Postoperative epidural analgesia is associated with a reduced incidence of CPSP after abdominal surgery.

Our study shows recovery of PLT function after transfusion in patients with thrombocytopenia. The majority of functional PLTs measured after transfusion most likely represents stored transfused PLTs that regained functionality in vivo. The difference in baseline P-selectin expression in vivo versus ex vivo suggests a rapid clearance from circulation of PLTs with increased P-selectin expression.

We hypothesized that improved acute postoperative pain relief will be achieved using general anaesthesia (GA) either in combination with continuous thoracic paravertebral block (GA-cPVB) or single shot (GA-sPVB) as compared to GA supplemented by local wound infiltration (GA-LWI) after unilateral major breast cancer surgery.A randomised controlled trial was conducted in 46 adult women in a day-care or short-stay hospital setting after major breast cancer surgery. Pain-intensity was measured using an 11-point visual analogue scale (VAS) until postoperative day 2. GA-sPVB was stopped due to slow inclusion.No significant difference in VAS score was noted between GA-LWI (VAS median 0.5 (interquartile range 0.18–2.00)) and GA-cPVB, (VAS 0.3 (0.00–1.55, p = 0.195)) 24 hours after surgery or at any point postoperatively until postoperative day 2.We conclude that both GA-LWI and GA-cPVB anaesthetic techniques are equally effective in treatment of acute postoperative pain after major oncological breast surgery. As GA-LWI is easily to perform with fewer complications and it is more cost-effective it should be preferred over GA-cPVB.

A case of an anaphylactic reaction to an old substancepatent bluefor a new indication Sir, We report an anaphylactic reaction due to patent blue allergy.Currently, patent blue is used in multiple oncological surgical sentinel node procedures (1), and an increasing number of cases of severe anaphylaxis has appeared in the literature (2, 3).Patent blue is a dye frequently used in textiles, cosmetics, agriculture and medical products. In the 1970s and 1980s it was frequently used to perform lymphangiography, and skin-prick testing was advocated to predict allergic reactions, as 2.7% of the population was sensitized to the dye (4).In our opinion there should be more consideration of testing patients with an increased risk to sensitization. In sensitized patients alternatives like technetium-99 m should be used.A 49-year-old woman with an atopic constitution was scheduled for lumpectomy and a sentinel node procedure in an outpatient setting. Anaesthesia was induced with propofol 2.5 mg kg À1 and sufentanil, and continued with sevoflurane after a laryngeal mask was introduced without any problems.Twenty minutes after induction severe hypotension developed, not reacting to the ephedrine. At the same time the patient seemed bronchospastic, although it was not very severe.The patient was treated with epinephrine, clemastine and hydrocortisone i.v. As the surgical drapes were removed a severe exanthema became obvious. The patient was intubated and after stabilization of hemodynamics the procedure was continued uneventfully, taking extra precautions assuming a latex or patent blue allergy. Blood samples were taken for allergologic testing. The patient was extubated and monitored for 24 h in our recovery room and referred to the Department of Dermatology for allergy consultation. As tryptase levels were increased, 74 mg l À1 (normal <10 mg l À1 ), IgE latex was negative and re-exposure to patent blue was considered too dangerous; an anaphylactic reaction due to patent blue was assumed to be the most probable cause. If necessary, Technetium-99 m could be a useful alternative in order to avoid another exposure to patent blue (5).

This study could not confirm good agreement between the ultrasound-estimated volumes and the injected volumes at volumes below 5 ml/kg. Bladder volumes were underestimated with a very broad 95% confidence interval. The ultrasound device should not replace current clinical assessment.