Thrombotic thrombocytopenic purpura can mimic HELLP syndrome late in gestation. Lack of response to dexamethasone within 12-24 hours and atypical relationships among laboratory values are two clues that thrombotic thrombocytopenic purpura may be the underlying pathology and that plasma exchange is emergently needed.
T he authors believe this is the first report of the successful use of lipid emulsion (Intralipid) in a prearrest situation and the first of cardiac arrhythmia and cardiovascular collapse following levobupivacaine administration in a peripheral nerve block. The 75-year-old ASA III woman presented for repair of a fractured femur, with a history of severe chronic obstructive pulmonary disease.With a normal preoperative electrocardiogram (ECG), a lumbar plexus block was begun at L4, after several unsuccessful attempts to place a subarachnoid block. Following negative aspiration, levobupivacaine 0.5% was injected slowly to a total of 20 mL; aspiration continued to be negative. Within seconds, the woman became unresponsive, followed by tonic-clonic convulsions, and a presumptive diagnosis of local anesthetic toxicity due to intravascular injection of levobupivacaine was made. Continuous, lead II ECG traces demonstrated deteriorating QRS morphology with reduced voltage and broadening complexes. Carotid pulse remained palpable and a second convulsion occurred 2 minutes after the first one. An intravenous bolus of metaraminol 0.5 mg was given and the airway secured with propofol and suxamethonium. Within 4 minutes of levobupivacaine injection, Intralipid 20% solution (100 mL) was infused over 5 minutes via the peripheral cannula, resulting in a rapid normalization of QRS morphology and no more convulsions. The patient's hemodynamics and ECG traces remained stable and surgery proceeded with volatile anesthesia. She continued to improve and the surgery was uneventful, as was recovery.Lipid emulsion has been used successfully to treat local anesthetic-induced cardiovascular collapse in animals and in 2 cases of cardiac arrest in humans. Cardiac arrest has been reported following intrathecal spread of local anesthetic during posterior lumbar plexus block and generalized tonic-clonic seizures have been seen in a 27-yearold patient following presumed intravenous injection of levobupivacaine, but with no ECG abnormalities or cardiovascular instability. There also have been reports of central nervous system toxicity and seizures following accidental intravascular injection of levobupivacaine. With reports of beneficial effects of Intralipid administration in local anesthetic toxicity, the authors have placed Intralipid in all theater areas for rapid accesses. They recommended continuing collection of reported uses of this lipid emulsion, both successful and unsuccessful, to reach a consensus on its efficacy and appropriateness.
Vertical alliances in beef are growing in importance. Alliances struggle with decisions on how to compensate members. Both conceptual development and empirical analysis are needed. A conceptual framework building on transaction cost and principal agent literature is developed and strategies for sharing feeding and packing margins are analyzed. Premiums for high-quality cattle increase revenues to the alliance. Margin and premium sharing interactions are investigated and guidelines are presented. Compensations that provide incentives for improving cattle quality help ensure the success of alliances as vertical coordination and quality control mechanisms.T he beef sector is experiencing significant change in coordination of activities along the supply chain. Historically, there have been separate profit centers between the producer and consumer with reliance on the price system to ensure coordination between what is produced and what consumers want. Since the late 1970s, the effectiveness of price as a coordinating mechanism has been questioned. Demand decreases have persisted and accumulated. A demand index developed for the National Cattlemen's Beef Association indicates beef demand decreased more than 49% between 1980 and 1998 (Demand Indexes at
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