General anaesthesia for obstetric surgery has distinct characteristics that may contribute towards a higher risk of accidental awareness during general anaesthesia. The primary aim of this study was to investigate the incidence, experience and psychological implications of unintended conscious awareness during general anaesthesia in obstetric patients. From May 2017 to August 2018, 3115 consenting patients receiving general anaesthesia for obstetric surgery in 72 hospitals in England were recruited to the study. Patients received three repetitions of standardised questioning over 30 days, with responses indicating memories during general anaesthesia that were verified using interviews and record interrogation. A total of 12 patients had certain/ probable or possible awareness, an incidence of 1 in 256 (95%CI 149-500) for all obstetric surgery. The incidence was 1 in 212 (95%CI 122-417) for caesarean section surgery. Distressing experiences were reported by seven (58.3%) patients, paralysis by five (41.7%) and paralysis with pain by two (16.7%). Accidental awareness occurred during induction and emergence in nine (75%) of the patients who reported awareness. Factors associated with accidental awareness during general anaesthesia were: high BMI (25-30 kg.m -2 ); low BMI (<18.5 kg.m -2 ); out-of-hours surgery; and use of ketamine or thiopental for induction. Standardised psychological impact scores at 30 days were significantly higher in awareness patients (median (IQR [range]) 15 (2.7-52.0 [2-56]) than in patients without awareness 3 (1-9 [0-64]), p = 0.010. Four patients had a provisional diagnosis of post-traumatic stress disorder. We conclude that direct postoperative questioning reveals high rates of accidental awareness during general anaesthesia for obstetric surgery, which has implications for anaesthetic practice, consent and follow-up.
Pulmonary hydatid disease still remains an important healthcare problem. Conservative operative interventions including cystotomy or cystotomy with capitonnage are the two commonly used techniques. There is still significant controversy, however, over selection of these two procedures. In this retrospective analysis of 66 patients with hydatid disease, we employed three types of interventions, Group A, (n = 5) cystotomy alone with closure of bronchial openings; Group B, (n = 54) cystotomy with capitonnage and Group C, (n = 7) lobectomy over a period of seven years in our patients and compared their postoperative outcome in terms of morbidity and mortality. Our data show that cystotomy with capitonnage is associated with low rates of postoperative prolonged air leak, bronchopleural fistula formation, empyema formation [mean complication rate 0.12% (Mean 0.08; 0.151-95% CI)] as compared to cystotomy alone with closure of bronchial openings [mean complication rate 44% (Mean 2.20; 3.18-95% CI)]. The lobectomy group was excluded from the comparison, as this approach is quite different from the cystostomy based enucleation techniques. We conclude that capitonnage with cystotomy may be a preferred procedure due to its lower rate of complications.
was 69.2 years (range 33-92 years). 119 (65%) had mild, 58 (32%) moderate and 5 (3%) severe hyponatraemia. 74 (40%) were adenocarcinomas, 58 (32%) squamous carcinomas, 43 (24%) SCLC and 7 (4%) had unspecified non-small cell lung cancer. 89(49%) had metastatic disease at diagnosis. 18/43 (42%) small cell, 14/58 (33%) squamous, 23/74 (31%) adenocarcinoma patients had moderate to severe hyponatraemia. 132 (74%) of this cohort had active oncological treatment: 93 (51%) chemotherapy, 25 (14%) radiotherapy, 17 (9%) surgery whilst 47 (26%) had best supportive care. 28 (15%) had a biochemical response to treatment, 11 (39%) of these patients were adenocarcinomas, 10 (36%) squamous carcinomas and 7 (25%) SCLC. Conclusion: Hyponatraemia in lung cancer patients is widely distributed in various age groups and histological subtypes. Among those admitted with hyponatraemia, severe cases (<124mEq/L) were rare. Higher rates of SIADH are seen in SCLC than in any other malignancy and our data confirmed that, proportionately, more SCLC patients had moderate e severe hyponatremia than non-small cell lung cancer patients. Hyponatraemia does respond to active oncological treatment including chemotherapy, radiotherapy and surgery. Although historically, hyponatraemia is considered as a poor prognostic marker, this should not preclude active oncological management. Asymptomatic patients with SIADH have been managed initially by fluid restriction but patient compliance is usually poor. Older medications such as demeclocycline, urea and lithium are limited by variable efficacy, poor palatability and/or toxicity, thus underscoring the need for new approaches. Tolvaptan, a new vasopressin receptor antagonist, can improve hyponatraemia due to SIADH. Further studies are needed to evaluate the prognostic value of hyponatraemia and its treatment in cancer patients.
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