Our experience of this technique has been very positive, with excellent control of both obstructive and infective symptoms, and exceptionally low rates of complications. Further work will be required to allow conclusive demonstration of its advantages over extracapsular tonsillectomy.
We describe our airway management in a patient requiring emergency laparotomy with a Montgomery T-tube in situ. This uncuffed silicone T-tube acts as both stent and tracheostomy after laryngotracheal surgery, and entails various difficulties for the anaesthetist. Several anaesthetic techniques have been described for T-tube insertion. The management of patients with a T-tube in situ, at risk of pulmonary aspiration, has not been addressed. Below, we present some possible approaches to this problem and describe how we successfully carried out an awake fibreoptic intubation via the tracheal limb of the T-tube. This technique might be considered for patients in similar circumstances, but knowledge of relevant internal and external tube diameters, and appropriate tracheal tube size selection, is crucial.
after the administering of insulin, unlike the glucose response, which requires 30-60 min. The marked resistance of the glycemic metabolism to insulin makes the coadministering of glucose unnecessary and it is better to monitor glycemia at 30-min intervals (4). Here, the greater need for glucose after reperfusion, even with good signs of the functioning of the graft was attributed to the longer plasma half-life of the insulin because of CRI.TEG measures the viscoelastic and mechanical properties of the developing clot. TEG allows a differential diagnosis of the coagulopathy and separation of surgical and non-surgical bleeding. It allows in vitro tests, such as therapeutic trials, but is unable to identify the specific factor in deficiency (5). During LT, heparinoids may appear after reperfusion of the graft and normally exhibit a self-limited behavior because of their rapid elimination. The inclusion of protamine in the TEG examination removes the heparin-like effect from the parameters of the sample tested, serving as a therapeutic trial (6). The presence of heparinoids was attributed to its longer elimination half-life associated to renal insufficiency. Protamine was administered to counteract the heparinlike action of the heparinoids, with a clinical improvement in bleeding. The aim was not the normalization of coagulation, but to avoid bleeding while the cause (heparinoids) was eliminated by the organism. With TEG, the infusion of blood products was guided, avoiding hypervolemia, trombosis of the anastomoses and the exposition of the patient to all risks associated to transfusions.In our case, a meticulous anesthesia technique, considering all the particularities of the patient, resulted in a successful transplant with no need for postoperative blood transfusions, re-operation because of bleeding or vascular thrombosis or urgent hemodialysis due to hydroelectrolytic disorders or hypervolemia.Fa bi ano S oa re s Ca rne iro * † Cris ti ano Hiroshi H o ri guthi * 49: 89-95.6 Coakley M, Reddy K, Mackie I et al. Transfusion triggers in orthotopic liver transplantation: A comparison of the thromboelastometry analyzer, the thromboelastogram, and conventional coagulation tests.SIR IR-We would like to report a case of a severe hypersensitivity reaction to basiliximab in a 7-month-old female infant, who presented for heart transplantation at our institution. She had been diagnosed with dilated cardiomyopathy (Fractional shortening = 6.7%) at 7 weeks of age. This was her second presentation for cardiac transplant; she had been scheduled for cardiac transplant 2 months previously but the procedure had been cancelled because of donor complications. She had received basiliximab as part of her induction immunosupression on the first presentation, immediately prior to cancellation of the procedure. On this occasion, induction of anesthesia with ketamine 1 mgAEkg )1 and fentanyl 3 lgAEkg )1 was uneventful. A nasotracheal tube was inserted after pancuronium 0.2 mgAEkg )1 . Arterial and central venous access was then secured wh...
absorbencies, of pulsatile arterial blood to nonpulsatile arterial blood, venous and capillary blood and tissue. Especially in the newborn and neonatal population, increases in venous pooling or decreases in pulsatile flow would decrease the ratio thereby decreasing pulse oximetry saturation.Our report of a 1-h-old female newborn with gastroschsis demonstrates the possible efficacy of dual pulse oximetry monitoring. The patient was 37 weeks estimated gestational age. She underwent a stage 1 closure with silastic silo placement. The initial procedure was about 1 h without complication. Patient remained intubated, sedated and paralyzed postoperatively. Stage 2 closure was done 6 days later. Pulse oximetry was placed on right foot and left hand. Both oximetry components were equivalent at the initiation of the case at 95% saturation. The dual oximetry sites were monitored continuously throughout the case. Upon manipulation of the bowels into the abdominal cavity and closure of the abdominal wall the saturation in the lower extremity decreased by 5-8%. The lowest value of saturation was 87% in the lower extremity. The upper extremity saturation remained constant at 95%. After closure of the abdominal wall, both pulse oximeter readings re-equilibrated within 3-5 min at 95% and remained at this level for the remainder of the case. No other IAP monitoring methods were utilized during the care of this patient. The patient tolerated the procedure and recovered with no oliguria or bowel complications postoperatively.Intra-abdominal pressure monitoring is important in deceasing morbidity associated with gastroschisis and abdominal wall defect management in newborns. Many of the available modes of monitoring IAP are invasive, costly or reliant on specialty trained professionals. Monitoring pulse oximetry proximal and distal to the abdomen simultaneously demonstrates promise with regard to detecting decreases in venous return, decreases in arterial perfusion in the lower extremities and ultimately IAP. This data is real-time, noninvasive and cost-effective. Its efficacy would be useful preoperatively, perioperatively and postoperatively. Clinical trials correlating this dual pulse oximetry method to IAP and other monitoring methods would determine its efficacy and value in the management of abdominal wall defects in newborns.
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