The common causes of rhabdomyolysis include trauma, hypoxia, drugs, toxins, infections and hyperthermia. Operative insults, including direct trauma and ischemia, have the potential to cause the development of rhabdomyolysis. Pneumatic tourniquets used during arthroscopic knee surgery to prevent blood loss have led to many complications such as nerve paralysis and vascular injuries. Rhabdomyolysis can also be caused by prolonged pneumatic tourniquet application without a midapplication release, and also from an increased application pressure, but the actual incidence of this is low. In order to prevent rhabdomyolysis, the clinicians must be aware of such risks and follow strict guidelines for the application time, the midapplication release and also the inflation pressure. Vigorous hydration and postoperative patient surveillance are helpful to prevent rhabdomyolysis. We have recently experienced a case of rhabdomyolysis after the arthroscopic knee surgery, and the rhabdomyolysis could have been associated with the use of a pneumatic tourniquet.
Rhabdomyolysis; Tourniquets; Kidney failure, acute
To document any consistent clinical findings in a large cohort of patients with whiplash associated disorder.
Four-year observational study.
Large orthopaedic medicolegal practice in the UK.
1025 consecutive cases of chronic whiplash associated disorder.
Main outcome measures
Observational study of the clinical features of whiplash associated disorder: detailed examination
Three consistent clinical features: neck pain; reduced cervical spine range of motion; and myofascial-entheseal dysfunction. With regards to the myofascial-entheseal dysfunction there were trigger points in the upper, middle or lower trapezius; with or without enthesopathy in the lower or middle trapezius.
On the basis of this large observational experience we propose a clinically-based definition of chronic whiplash associated disorder: a painful syndrome following acceleration-deceleration injury with neck stiffness; and myofascial-entheseal dysfunction.
STUDY OBJECTIVE--The extent to which patients undergoing elective surgery for orthopaedic disorders were incapacitated for work while they were on the waiting list and whether they were able to return to work after surgery were studied. DESIGN--This was a prospective cohort study of patients admitted to hospital for elective orthopaedic surgery. Main outcome measures were occurrence of sickness certification during the waiting time, and whether those incapacitated for work at the time of surgery returned to work during the first year after treatment. Multivariate logistic regression was used to estimate adjusted odds ratios for factors influencing return to work. SETTING--Orthopaedic department in charge of all elective orthopaedic surgery in a population of 197,354 persons in central Norway. SUBJECTS--All 2803 patients admitted to hospital for chronic orthopaedic disorders in the defined population between 1 September 1988 and 31 August 1990 were included in the study. MAIN RESULTS--Of the 1333 patients who were employed, 42% had been certified sick due to the orthopaedic disorder for some period of the waiting time. Sickness benefits from the national insurance scheme (paid from the 15th day of sickness certification) had been received by 33% and were received by 29% at the time of surgery. Of 380 patients incapacitated for work at the time of surgery, 53% returned to work within the first year after surgery. Using those treated within one month of being placed on the waiting list as the reference group, the adjusted odds ratios for not returning to work during the first year after surgery were 9.2 (p < 0.0001) for those who waited more than a year for surgery, 6.2 (p = 0.002) for those waiting nine to 12 months, and 4.9 (p = 0.02) for those waiting for six to nine months. CONCLUSIONS--A high proportion of these patients were incapacitated for work, 53% of those incapacitated returned to work within the first year after surgery. The probability of returning to work after surgery is strongly influenced by the length of time on the waiting list. Waiting for more than one year, compared with immediate treatment, was associated with an adjusted odds ratio of 9.2 for not returning to work.
Understanding the factors that impact on disability is necessary to inform trauma care and enable adequate risk adjustment for benchmarking and monitoring. A key consideration is how to adjust for pre-existing conditions when assessing injury outcomes, and whether the inclusion of comorbidity is needed in addition to adjustment for age. This study compared different approaches to modelling the impact of comorbidity, collected as part of the routine hospital episode data, on disability outcomes following orthopaedic injury.
12-month Glasgow Outcome Scale – Extended (GOS-E) outcomes for 13,519 survivors to discharge were drawn from the Victorian Orthopaedic Trauma Outcomes Registry, a prospective cohort study of admitted orthopaedic injury patients. ICD-10-AM comorbidity codes were mapped to four comorbidity indices. Cases with a GOS-E score of 7–8 were considered “recovered”. A split dataset approach was used with cases randomly assigned to development or test datasets. Logistic regression models were fitted with “recovery” as the outcome and the performance of the models based on each comorbidity index (adjusted for injury and age) measured using calibration (Hosmer-Lemshow (H-L) statistics and calibration curves) and discrimination (Area under the Receiver Operating Characteristic (AUC)) statistics.
All comorbidity indices improved model fit over models with age and injuries sustained alone. None of the models demonstrated acceptable model calibration (H-L statistic p < 0.05 for all models). There was little difference between the discrimination of the indices for predicting recovery: Charlson Comorbidity Index (AUC 0.70, 95% CI: 0.68, 0.71); number of ICD-10 chapters represented (AUC 0.70, 95% CI: 0.69, 0.72); number of six frequent chronic conditions represented (AUC 0.70, 95% CI: 0.69, 0.71); and the Functional Comorbidity Index (AUC 0.69, 95% CI: 0.68, 0.71).
The presence of ICD-10 recorded comorbid conditions is an important predictor of long term functional outcome following orthopaedic injury and adjustment for comorbidity is indicated when assessing risk-adjusted functional outcomes over time or across jurisdictions.
Orthopaedic injury; Comorbidity; Disability outcomes; Prediction
The macrolide antibiotics clarithromycin and erythromycin may potentiate calcium-channel blockers by inhibiting cytochrome P450 isoenzyme 3A4. However, this potential drug interaction is widely underappreciated and its clinical consequences have not been well characterized. We explored the risk of hypotension or shock requiring hospital admission following the simultaneous use of calcium-channel blockers and macrolide antibiotics.
We conducted a population-based, nested, case-crossover study involving people aged 66 years and older who had been prescribed a calcium-channel blocker between Apr. 1, 1994, and Mar. 31, 2009. Of these patients, we included those who had been admitted to hospital for the treatment of hypotension or shock. For each antibiotic, we estimated the risk of hypotension or shock associated with the use of a calcium blocker using a pair-matched analytic approach to contrast each patient’s exposure to each macrolide antibiotic (erythromycin, clarithromycin or azithromycin) in a seven-day risk interval immediately before admission to hospital and in a seven-day control interval one month earlier.
Of the 7100 patients admitted to hospital because of hypotension while receiving a calcium-channel blocker, 176 had been prescribed a macrolide antibiotic during either the risk or control intervals. Erythromycin (the strongest inhibitor of cytochrome P450 3A4) was most strongly associated with hypotension (odds ratio [OR] 5.8, 95% confidence interval [CI] 2.3–15.0), followed by clarithromycin (OR 3.7, 95% CI 2.3–6.1). Azithromycin, which does not inhibit cytochrome P450 3A4, was not associated with an increased risk of hypotension (OR 1.5, 95% CI 0.8–2.8). We found similar results in a stratified analysis of patients who received only dihydropyridine calcium-channel blockers.
In older patients receiving a calcium-channel blocker, use of erythromycin or clarithromycin was associated with an increased risk of hypotension or shock requiring admission to hospital. Preferential use of azithromycin should be considered when a macrolide antibiotic is required for patients already receiving a calcium-channel blocker.
Diverticulosis is a common disease in the western society with an incidence of 33–66%. 10–25% of these patients will develop diverticulitis. In order to prevent a high-risk acute operation it is advised to perform elective sigmoid resection after two episodes of diverticulitis in the elderly patient or after one episode in the younger (< 50 years) patient. Open sigmoid resection is still the gold standard, but laparoscopic colon resections seem to have certain advantages over open procedures. On the other hand, a double blind investigation has never been performed. The Sigma-trial is designed to evaluate the presumed advantages of laparoscopic over open sigmoid resections in patients with symptomatic diverticulitis.
Indication for elective resection is one episode of diverticulitis in patients < 50 years and two episodes in patient > 50 years or in case of progressive abdominal complaints due to strictures caused by a previous episode of diverticulits. The diagnosis is confirmed by CT-scan, barium enema and/or coloscopy.
It is required that the participating surgeons have performed at least 15 laparoscopic and open sigmoid resections. Open resection is performed by median laparotomy, laparoscopic resection is approached by 4 or 5 cannula. Sigmoid and colon which contain serosal changes or induration are removed and a tension free anastomosis is created. After completion of either surgical procedure an opaque dressing will be used, covering from 10 cm above the umbilicus to the pubic bone. Surgery details will be kept separate from the patient's notes.
Primary endpoints are the postoperative morbidity and mortality. We divided morbidity in minor (e.g. wound infection), major (e.g. anastomotic leakage) and late (e.g. incisional hernias) complications, data will be collected during hospital stay and after six weeks and six months postoperative. Secondary endpoints are the operative and the postoperative recovery data. Operative data include duration of the operation, blood loss and conversion to laparotomy. Post operative recovery consists of return to normal diet, pain, analgesics, general health (SF-36 questionnaire) and duration of hospital stay.
The Sigma-trial is a prospective, multi-center, double-blind, randomized study to define the role of laparoscopic sigmoid resection in patients with symptomatic diverticulitis.
This study is performed to investigate risk factors of hypotension in response to elective carotid stenting. Forty-four lesions of 40 consecutive patients (mean age 70.4 ± 8.2 years) were retrospectively analyzed. Easy Wall stent was applied in 15 lesions and SMART stent in 29 lesions. We investigated correlations between the occurrence rate of postoperative hypotension below 90 mmHg and persisting over three hours and findings of preoperative angiograms, ultrasonograms and clinical characteristics. Postprocedural hypotension occurred in 19 patients (47.5%) and medical treatment (intravenous administration of catecholamines) was required in eleven patients (27.5%). Although there was no permanent neurological deficits related with postprocedural hypotension, transient neurological deficits were found in three patients. Risk factors of prolonged postprocedural hypotension were statistically analyzed. On angiographic characteristics; 1) distance between the carotid bifurcation and the lesion with maximum stenosis (≦10 mm vs. >10 mm: p = 0.031), 2) type of stenosis (eccentric vs. concentric: p = 0.014) On ultrasonographic characteristics; 1) calcifications at the carotid bifurcation (present vs. absent: p< 0.001). Other variables, including age and degree of stenosis, were not associated with postprocedural hypotension after carotid stenting. These angiographic and ultrasonographic variables can be used to identify patients at risk for postprocedural hypotension after carotid stenting. Such identification may help in selection of patients who will benefit from appropriate pharmacological treatment.
stent, postprocedural hypotension, prolonged, carotid artery
Few studies have documented the incidence and significance of non-sustained hypotension in emergency department (ED) patients with sepsis. We hypothesized that ED non-sustained hypotension increases risk of in-hospital mortality in patients with sepsis.
Secondary analysis of a prospective cohort study. ED patients aged >17 years admitted to the hospital with explicitly defined sepsis were prospectively identified.
Evidence of systemic inflammation (>1 criteria) and suspicion for infection. Patients with overt shock were excluded. The primary outcome was in-hospital mortality.
Seven hundred patients with sepsis were enrolled, including 150 (21%) with non-sustained hypotension. The primary outcome of in-hospital mortality was present in 10% (15/150) of patients with non-sustained hypotension compared with 3.6% (20/550) of patients with no hypotension. The presence of non-sustained hypotension resulted in three times the risk of mortality than no hypotension (risk ratio = 2.8, 95% CI 1.5–5.2). Patients with a lowest systolic blood pressure <80 mmHg had a threefold increase in mortality rate compared with patients with a lowest systolic blood pressure ≥80 mmHg (5 vs. 16%). In logistic regression analysis, non-sustained hypotension was an independent predictor of in-hospital mortality.
Non-sustained hypotension in the ED confers a significantly increased risk of death during hospitalization in patients admitted with sepsis. These data should impart reluctance to dismiss non-sustained hypotension, including a single measurement, as not clinically significant or meaningful.
Hypotension; Sepsis; Shock; Mortality; Emergency medicine
OBJECTIVES—To determine whether continued methotrexate treatment increases the risk of postoperative infections or of surgical complications in patients with rheumatoid arthritis (RA) within one year of elective orthopaedic surgery.
DESIGN—A prospective randomised study of postoperative infection or surgical complications occurring within one year of surgery in patients with RA who underwent elective orthopaedic surgery.
SUBJECTS—388 patients with RA who were to undergo elective orthopaedic surgery. Patients who were receiving methotrexate were randomly allocated to groups who either continued methotrexate (group A) or who discontinued methotrexate from two weeks before surgery until two weeks after surgery (group B). Their complication rates were compared with complications occurring in 228 patients with RA (group C) who were not receiving methotrexate and who also underwent elective orthopaedic surgery.
MAIN OUTCOME MEASURES—Signs of postoperative infection were recorded, including rubor, discharge, systemic infection, and frequency of wound dehiscence as well as the incidence of any surgical complication requiring a secondary revision procedure that occurred within one year of surgery. The frequencies of flare up activity of RA at six weeks and six months after surgery were also recorded. A flare of rheumatoid disease was defined as an increase in joint pain in two or more joints notified by the patient as well as by an increase in articular index of at least 25% after surgery.
RESULTS—Signs of infection or surgical complications occurred in two of 88 procedures in group A (2%), 11 of 72 procedures in group B (15%), and 24 of 228 (10.5%) procedures in group C. The surgical complication or infection frequency in group A was less than that in either group B (p<0.003) or group C (p=0.026). At six weeks after surgery there were no flares in group A, six flares in group B (8%), and six flares in group C (2.6%). Logistic regression analysis of the overall surgical complication rate in all the patients with RA studied showed that methotrexate, whether continued or discontinued before surgery, did not increase the early complication rate in the patients with RA who underwent elective orthopaedic surgery. Other drugs—penicillamine, indometacin, cyclosporin, hydroxychloroquine, chloroquine, and prednisolone—all did significantly increase the risk of infection or surgical complication after elective orthopaedic surgery. The risk of surgery was also increased in the presence of intercurrent chronic diseases—diabetes, hypertension, bronchiectasis, psoriasis, asthma, and ischaemic heart disease.
CONCLUSION—Continuation of methotrexate treatment does not increase the risk of either infections or of surgical complications occurring in patients with RA within one year of elective orthopaedic surgery. Thus methotrexate treatment should not be stopped in patients whose disease is controlled by the drug before elective orthopaedic surgery.
To test the hypothesis that perioperative statin use reduces acute kidney injury (AKI) following cardiac surgery
Retrospective analysis of prospectively collected data from an ongoing clinical trial
Quaternary-care university hospital
Three hundred twenty-four elective adult cardiac surgery patients
Measurements and Main Results
We assessed the association of preoperative statin use, early postoperative statin use, and acute statin withdrawal with the incidence of AKI. Early postoperative statin use was defined as statin treatment within the first postoperative day. Statin withdrawal was defined as discontinuation of preoperative statin treatment prior to surgery until at least postoperative day 2. Logistic regression and propensity score modeling were used to control for AKI risk factors. Sixty-eight of 324 patients (21.0%) developed AKI. AKI patients stayed in the hospital longer (P=0.03) and were more likely to develop pneumonia (P=0.002) or die (P=0.001). Higher body mass index (P=0.003), higher central venous pressure (P=0.03), and statin withdrawal (27.4 vs. 14.7%, P=0.046) were associated with a higher incidence of AKI, while early postoperative statin use was protective (12.5 vs. 23.8%, P=0.03). Preoperative statin use did not affect risk of AKI. In multivariate logistic regression, age (P=0.03), male gender (P=0.02), body mass index (P<0.001), and early postoperative statin use (OR 0.32, 95% CI 0.14–0.72, P=0.006) independently predicted AKI. Propensity score-adjusted risk assessment confirmed the association between early postoperative statin use and reduced AKI (OR 0.30, 95% CI 0.13–0.70, P=0.005).
Early postoperative statin use is associated with a lower incidence of AKI among both chronic statin users and statin-naïve cardiac surgery patients.
acute kidney injury; acute renal failure; cardiac surgery; statin; oxidative stress; obesity
A randomised controlled trial of two management regimens was carried out in women patients over 65 years of age with hip fractures. Ninety seven patients were admitted to a designated orthopaedic geriatric unit and 125 to orthopaedic wards. No difference was observed in mortality, length of stay, or placement of patients between the two groups. More medical conditions were recognised and treated in patients in the orthopaedic geriatric unit group. It is concluded that designated orthopaedic geriatric units can provide medical care to these patients and should be administered without additional cost.
Arthritis is the leading cause of disability in the United States. Osteoarthritis, the most common form of arthritis, is a degenerative joint disease affecting both whites and African Americans similarly. African Americans have a high incidence rate of comorbidities, including hypertension, cardiovascular disease (CVD) risk factors and diabetes. Treatment of osteoarthritic pain in patients with comorbidities is often complicated by potential safety concerns. Traditional nonsteroidal antiinflammatory drugs (NSAIDs) and cyclooxygenase 2 (COX-2) specific NSAIDs have been shown to increase blood pressure in hypertensive patients taking antihypertensive medications. Patients with CVD risk factors taking low-dose aspirin for secondary prevention may be at increased risk for gastrointestinal bleeding with NSAIDs. Diabetics face an increased risk of renal complications. Because NSAIDs are associated with adverse renal effects, they should be used cautiously in patients with advanced renal disease. Acetaminophen is the most appropriate initial analgesic for African Americans with chronic osteoarthritic pain and concurrent hypertension, CVD risk factors or diabetes, and is recommended by the American College of Rheumatology as first-line treatment. Many of the adverse effects commonly associated with NSAIDs are not associated with acetaminophen. Safety concerns surrounding pharmacologic treatment of osteoarthritis in African Americans are reviewed.
Risk factors for heart failure (HF) may differ according to ejection fraction (EF). Higher cystatin C, a marker of kidney dysfunction, is associated with incident HF, but prior studies did not determine EF at diagnosis. We hypothesized that kidney dysfunction would predict diastolic HF (DHF) better than systolic HF (SHF) in the Cardiovascular Health Study.
Methods and Results
Cystatin C was measured in 4,453 participants without HF at baseline. Incident HF was categorized as DHF (EF ≥ 50%) or SHF (EF < 50%). We compared the association of cystatin C with risk for DHF and SHF, after adjustment for age, sex, race, medications, and HF risk factors. Over eight years of follow-up, 167 participants developed DHF and 206 SHF. After adjustment, sequentially higher quartiles of cystatin C were associated with risk for SHF [competing risks hazard ratios 1.0 (reference), 1.99 (95% CI 1.14, 3.48), 2.32 (1.32, 4.07), 3.17 (1.82, 5.50), P for trend <0.001]. Risk for DHF was apparent only at the highest cystatin C quartile [hazard ratios 1.0 (reference), 1.09 (0.62, 1.89), 1.08 (0.61, 1.93), 1.83 (1.07, 3.11)].
Cystatin C levels are linearly associated with incidence of systolic HF, whereas only the highest concentrations of cystatin C predict diastolic HF.
Heart failure; cystatin C; systolic heart failure; diastolic heart failure; estimated glomerular filtration rate; elderly; ejection fraction.
Two hundred and thirty five consecutive patients with a life threatening complication of peptic ulceration, who either died or required emergency surgery, have been studied over a 36 month period. Seventy eight of these high risk patients died; 25 at home, 19 in hospital without surgery and 34 postoperatively. Ninety eight patients had bleeding ulcers, 132 perforated ulcers and five had both bleeding and perforated ulcers. One hundred and forty one of these 235 patients (60%) were taking a non-steroidal anti-inflammatory drugs (NSAID) and the individual agents have been listed. The overall incidence of NSAID use in a hospital control group was 9.9%. The first sign of an ulcer was a life threatening complication in 58.2% of patients taking a NSAID. Nearly 80% of all ulcer related deaths occurred in patients using an anti-inflammatory agent. Patients using these drugs were older, with more pre-existing medical conditions and had larger ulcers than those not taking NSAIDs. The mortality associated with a peptic ulcer complication in patients taking a NSAID was more than twice that in patients with no such drug history. There appears to be a relationship between the development of a life threatening complication of peptic ulceration and NSAID ingestion. Much of the associated mortality and morbidity may be potentially avoidable.
OBJECTIVE--To investigate differences between hospitals in clinical management of patients admitted with fractured hip and to relate these to mortality at 90 days. DESIGN--A prospective audit of process and outcome of care based on interviews with patients, abstraction from records with standard proforma, and follow up at three months. Data were analysed with chi 2 test and forward stepwise regression modelling of mortality. SETTING--All eight hospitals in East Anglia with trauma orthopaedic departments. PATIENTS--580 consecutive patients admitted for fracture of neck of femur. MAIN OUTCOME MEASURE--Mortality at 90 days. RESULTS--Patients admitted to each hospital were similar with respect to age, sex, pre-existing illnesses, and activities of daily living before fracture. In all, 560 (97%) were treated surgically, by a range of grades of surgeon. Two hundred and sixty one patients (45%; range between hospitals 10-91%) received pharmaceutical thromboembolic prophylaxis, 502 (93%; 81-99%) perioperative antibiotic prophylaxis. The incidence of fatal pulmonary emboli differed between patients who received and those who did not receive prophylaxis against deep vein thrombosis (P = 0.001). Mortality at 90 days was 18%, differing significantly between hospitals (5-24%). One hospital had significantly better survival than the others (odds ratio 0.14; 95% confidence interval 0.04-0.48; P = 0.0016). CONCLUSIONS--No single factor or aspect of practice accounted for this protective effect. Lower mortality may be associated with the cumulative effects of several aspects of the organisation of treatment and the management of fracture of the hip, including thromboembolic pharmaceutical prophylaxis, antibiotic prophylaxis, and early mobilisation.
Diabetic nephropathy is the leading cause of kidney failure in the US. The extent to which elevated glycated hemoglobin (HbA1c) is associated with increased risk of chronic kidney disease (CKD) in the absence of albuminuria and retinopathy, the hallmarks of diabetic nephropathy, is uncertain.
HbA1c was measured in 1,871 adults with diabetes followed for 11 years in the Atherosclerosis Risk in Communities Study. Incident CKD was defined as an estimated glomerular filtration rate (GFR) below 60 mL/min/1.73 m2 after 6 years of follow-up or a kidney disease-related hospitalization. We categorized HbA1c into 4 clinically relevant categories. Retinopathy and albuminuria were measured midway through follow-up.
Higher HbA1c was strongly associated with risk of CKD in models adjusted for demographics, baseline GFR and cardiovascular risk factors. Compared to HbA1c values of <6.00%, HbA1cs of 6.00-7.00%, 7.00%-8.00%, and >8.00% had adjusted relative hazards of CKD of 1.4 (95% CI: 0.97-1.91), 2.5 (1.70-3.66) and 3.7 (2.76-4.90), respectively. Risk of CKD was higher among individuals with retinopathy and albuminuria, the association between HbA1c and incident CKD was observed even among those participants without either abnormality: adjusted relative hazards =1.46 (0.80-2.65), 1.17 (0.43-3.19) and 3.51 (1.67-7.40); p-trend=0.004.
We observed a positive association between HbA1c and incident CKD that was strong, graded, independent of traditional risk factors and present even in the absence of albuminuria and retinopathy. Hyperglycemia is an important indicator of risk of both diabetic nephropathy (with albuminuria or retinopathy) and of less specific forms of CKD.
Rhabdomyolysis is a potentially life-threatening condition resulting from the release of large quantities of myocyte breakdown products into the circulation, following injury to striated muscles. There are several causes of rhabdomyolysis - traumatic and non-traumatic. We present a 21-year-old male intravenous drug abuser, who was referred to us with fever, altered sensorium and seizures. He developed severe rhabdomyolysis following a mixed meningeal infection by Streptococcus pneumoniae and Mycobacterium tuberculosis. This patient’s examination and investigation suggested a combination of factors leading to the severe rhabdomyolysis which proved fatal. The patient’s creatine phosphokinase was elevated to 167,000 U/L, following hyperpyrexia, seizures, meningitis (pneumococcal and tuberculous), pentazocine and alcohol abuse. The increase in mortality rate with the onset of rhabdomyolysis warrants immediate cessation of the insult and aggressive management.
Background: Hypotension is commonly encountered in association with anaesthesia and surgery. Uncorrected and sustained it puts the brain, heart, kidneys, and the fetus in pregnancy at risk of permanent or even fatal damage. Its recognition and correction is time critical, especially in patients with pre-existing disease that compromises organ perfusion.
Objectives: To examine the role of a previously described core algorithm "COVER ABCD–A SWIFT CHECK", supplemented by a specific sub-algorithm for hypotension, in the management of hypotension when it occurs in association with anaesthesia.
Methods: Reports of hypotension during anaesthesia were extracted and studied from the first 4000 incidents reported to the Australian Incident Monitoring Study (AIMS). The potential performance of the COVER ABCD algorithm and the sub-algorithm for hypotension was compared with the actual management as reported by the anaesthetist involved.
Results: There were 438 reports that mentioned hypotension, cardiovascular collapse, or cardiac arrest. In 17% of reports more than one cause was attributed and 550 causative events were identified overall. The most common causes identified were drugs (26%), regional anaesthesia (14%), and hypovolaemia (9%). Concomitant changes were reported in heart rate or rhythm in 39% and oxygen saturation or ventilation in 21% of reports. Cardiac arrest was documented in 25% of reports. As hypotension was frequently associated with abnormalities of other vital signs, it could not always be adequately addressed by a single algorithm. The sub-algorithm for hypotension is adequate when hypotension occurs in association with sinus tachycardia. However, when it occurs in association with bradycardia, non-sinus tachycardia, desaturation or signs of anaphylaxis or other problems, the sub-algorithm for hypotension recommends cross referencing to other relevant sub-algorithms. It was considered that, correctly applied, the core algorithm COVER ABCD would have diagnosed 18% of cases and led to resolution in two thirds of these. It was further estimated that completion of this followed by the specific sub-algorithm for hypotension would have led to earlier recognition of the problem and/or better management in 6% of cases compared with actual management reported.
Conclusion: Pattern recognition in most cases enables anaesthetists to determine the cause and manage hypotension. However, an algorithm based approach is likely to improve the management of a small proportion of atypical but potentially life threatening cases. While an algorithm based approach will facilitate crisis management, the frequency of co-existing abnormalities in other vital signs means that all cases of hypotension cannot be dealt with using a single algorithm. Diagnosis, in particular, may potentially be assisted by cross referencing to the specific sub-algorithms for these.
Gluteal compartment syndrome (GCS) is an extremely rare and potentially devasting disorder, most commonly caused by gluteal muscle compression in extend periods of immobilization. We report a 65-year-old obese man with hypertension, diabetes mellitus type 2 and hypercholesterolemia underwent lumbar spine surgery in knee-chest position because of degenerative lumbar stenosis. Perioperative hypotension occurred. After surgery, the patient developed increasing pain in the buttocks of both sides and oliguria with darkened urine. Stiffness, tenderness and painful swelling of patients gluteal muscles of both sides, high creatine phosphokinase level, myoglobulinuria and oliguria led to diagnosis of bilateral GCS, complicated by severe rhabdomyolysis (RM) and acute renal failure. In conclusion, obese patients with vascular risk factors and perioperative hypotension may be at risk for developing bilateral GCS and RM when performing prolonged lumbar spine surgery. Early diagnosis and treatment is important, as otherwise, the further course may be fatal.
Gluteal compartment syndrome; Kidney failure; Lumbar spine; Neurosurgery; Rhabdomyolysis
Rhabdomyolysis is a severe and debilitating condition that promotes muscle breakdown and is a relatively rare, not always diagnosed cause of acute renal failure (ARF) with an 8–20% reported incidence. Exertional rhabdomyolysis only appears in adult patients 24–48 h after strenuous activities as military basic training, weight lifting, and marathon running.
A 30-year-old man was admitted to our department because of weakness and painful swelling of the muscles as well as dark urine appearing 24 h after carrying out a body-building exercises of low intensity. The development of an acute exertional rhabdomyolysis was confirmed by the increased serum enzyme levels and myoglobinuria. The patient was treated with intravenous sodium chloride, and sodium bicarbonate. The nephrotoxicity of myoglobin was decreased by forced alkaline diuresis.
The reported case emphasizes the occurrence of acute rhabdomyolysis even in those who underwent a low-intensity exercise. A proper treatment is mandatory to avoid a sudden worsening of clinical conditions eventually evolving to acute renal failure.
Autonomic nervous system (ANS) dysfunction is present in up to one third of patients with tetanus. The prognostic value of ANS dysfunction is known in severe tetanus but its value is not well established in mild to moderate tetanus.
Medical records of all patients admitted with tetanus at two academic tertiary care centers in Karachi, Pakistan were reviewed. The demographic, clinical and laboratory data was recorded and analyzed. ANS dysfunction was defined as presence of labile or persistent hypertension or hypotension and sinus tachycardia, tachyarrythmia or bradycardia on EKG. Patients were divided into two groups based on presence of ANS dysfunction (ANS group and non ANS group). Tetanus severity was classified on the basis of Ablett criteria.
Ninety six (64 males; 32 females) patients were admitted with the diagnosis over a period of 10 years. ANS group had 31 (32%) patients while non ANS group comprised of 65 (68%) patients. Both groups matched for age, gender, symptom severity, use of tetanus immunoglobulin and antibiotics. Twelve patients in ANS group had mild to moderate tetanus (Ablett I and II) and 19 patients had severe/very severe tetanus (Ablett III and IV). Fifteen (50%) patients in ANS group required ventilation as compared to 28 (45%) in non-ANS group (p = 0.09). Fourteen (47%) patients died in ANS group as compared to 10 (15%) in non ANS group (p= 0.002). Out of those 14 patients died in ANS group, six patients had mild to moderate tetanus and eight patients had severe/ very severe tetanus. Major cause of death was cardiac arrhythmias (13/14; 93%) in ANS group and respiratory arrest (7/10; 70%) in non ANS group. Ten (33%) patients had complete recovery in ANS group while in non ANS group 35(48%) patients had complete recovery (p= 0.05).
ANS dysfunction was present in one third of our tetanus population. 40% patients with ANS dysfunction had only mild to moderate tetanus. ANS dysfunction, irrespective of the need of mechanical ventilation or severity of tetanus, predicted poor outcome.
Exercise-induced rhabdomyolysis has been described in military recruits, trained athletes and daily runners. Statin use, quail ingestion, infection by Epstein-Barr virus (EBV), and hypothyroidism, though rare, are risk factors for the development of rhabdomyolysis. We describe the case of a 15-year-old female who presented with myalgias, weakness, and pigmenturia following marching band practice. Laboratory tests confirmed an elevated creatine kinase (CK) level as well as a profound hypothyroid state. Muscle biopsy revealed severe muscle necrosis and myositis. Treatment with levothyroxine resulted in obtaining an euthyroid state and regain of muscle strength as well as decrease in CK levels. Although rare, hypothyroidism should be considered as a potential cause of rhabdomyolysis in pediatric patients undergoing a myopathy workup.
A case is described of a patient who developed rhabdomyolysis and acute renal failure after the use of an intraoperative tourniquet for elective orthopaedic surgery. A review of the literature revealed four similar cases in the last 20 years. The clinical features and management of such patients are discussed.
Non steroidal anti-inflammatory drugs (NSAIDs) increase mortality and morbidity after myocardial infarction (MI). We examined cause-specific mortality and morbidity associated with NSAIDs in a nationwide cohort of MI patients.
Methods and Results
By individual-level linkage of nationwide registries of hospitalization and drug dispensing from pharmacies in Denmark, patients aged >30 years admitted with first-time MI during 1997–2009 and their subsequent NSAID use were identified. The risk of three cardiovascular specific endpoints: cardiovascular death, the composite of coronary death and nonfatal MI, and the composite of fatal and nonfatal stroke, associated with NSAID use was analyzed by Cox proportional hazard analyses. Of 97,698 patients included 44.0% received NSAIDs during follow-up. Overall use of NSAIDs was associated with an increased risk of cardiovascular death (hazard ratio [HR] 1.42, 95% confidence interval [CI] 1.36–1.49). In particular use of the nonselective NSAID diclofenac and the selective cyclooxygenase-2 inhibitor rofecoxib was associated with increased risk of cardiovascular death (HR 1.96 [1.79–2.15] and HR1.66 [1.44–1.91], respectively) with a dose dependent increase in risk. Use of ibuprofen was associated with increased risk of cardiovascular death (HR 1.34[1.26–1.44]), whereas naproxen was associated with the lowest risk of (e.g., HR 1.27[1.01–1.59].
Use of individual NSAIDs is associated with different cause-specific cardiovascular risk and in particular rofecoxib and diclofenac were associated with increased cardiovascular morbidity and mortality. These results support caution with use of all NSAIDs in patients with prior MI.
Coagulopathy is a common complication of snakebite, but there is little information on the clinical importance of coagulopathy. We analyzed the characteristics of coagulopathy after envenomation.
Ninety-eight patients who experienced snakebite were enrolled in this study. We divided all the patients into three groups by the ISTH DIC scoring system: the normal, simple coagulopathy and DIC groups. The coagulopathy group included both the simple coagulopathy and DIC groups. We then conducted a case-control study.
There was a significant decrease in the Hct, protein, albumin, ALP and cholesterol levels in the coagulopathy group, and only the cholesterol level was deceased in the DIC group (p<0.05). Leukocytosis and rhabdomyolysis were significantly associated with coagulopathy, and hemolysis and rhabdomyolysis were associated with DIC (p<0.05). The presence of rhabdomyolysis was considered a risk factor for coagulopathy (p<0.05). These conditions continued for up to six to seven days after the snakebite.
Evaluation of coagulopathy with using these characteristics is helpful to properly manage the patients who experience snakebite.