Postoperative Thoracic Epidural Analgesia: Adverse Events from a Single-Center Series of 3126 Patients

Purpose

Thoracic epidural analgesia (TEA) has been shown to reduce postsurgical morbidity and mortality; nevertheless, major and minor complications can occur. We report our 10-year experience with TEA and incidence of complications.

Patients and Methods

Patients received continuous infusion TEA (0.2% ropivacaine and 2 µg ml⁻¹ fentanyl) to control postoperative pain. Every 8 hours, the acute pain service recorded the analgesia regimen and occurrence of side effects. The initial infusion rate was tapered daily in response to improvement in pain symptoms or occurrence of side effects.

Results

A total of 3126 patients received TEA. The median age was 65 years (range, 18–94) and the duration of catheter placement was 3.5 days (range, 2–8). Three major complications were identified (1:1042): two subarachnoid blocks and one epidural abscess which led to permanent sequela (1:3126). Minor complications were hypotension (4.8%), pruritus (4.4%), accidental catheter removal (3.7%), insertion site inflammation (2.5%), motor weakness (2.0%), postoperative nausea and vomiting (1.8%), catheter disconnection (1.9%), catheter occlusion (0.3%), post-dural puncture headache (0.5%), and catheter fragment retention (0.06%), which were the reasons for a 7.4% rate of early discontinuation of epidural analgesia. No occurrence of epidural hematoma, local anesthetic systemic toxicity, and cardiovascular/respiratory depression was recorded.

Conclusion

Postoperative TEA is an advanced technique that poses certain difficulties that can subvert its great potential. While serious complications were rare, minor complications occurred more often and affected the postoperative course negatively. A risk/benefit evaluation of each patient should be done before employing the technique.

Spread patterns and effectiveness for surgery after ultrasound-guided rectus sheath block in adult day-case patients scheduled for umbilical hernia repair

BACKGROUND AND AIMS

We conducted a prospective study to examine the local anesthetic (LA) spread and the effectiveness for surgical anesthesia of ultrasound (US)-guided rectus sheath block (RSB) in adult patients undergoing umbilical hernia repair.

MATERIAL AND METHODS

Thirty patients received at T-10 level a bilateral US-guided injection of 20 mL levobupivacaine 0.375% + epinephrine 5 μg/mL behind the rectus muscle to detach it from its sheath. Anesthetic spread into the rectus sheath was evaluated ultrasonographically at T-9 and T-11 levels and scored from 0 to 4. The RSB was defined effective for surgical anesthesia if it was able to guarantee an anesthetic level sufficient for surgery without any mepivacaine supplementation.

RESULTS

Overall, the block was effective for surgical anesthesia in 53.3% of patients (95% confidence interval, ±17.8). In the remaining patients, anesthesia supplementation was needed at cutaneous incision, whereas manipulation of the muscle and fascial planes was painless. No patients required general anesthesia. LA spreads as advocated (to T-9 and to T-11 bilaterally = spread score 4) in 8/30 patients (26.6%); in these cases, the block was 75% effective for surgery. The anesthetic spread was most negatively influenced by increased body mass index. Postoperative analgesia was excellent in 97% of patients.

CONCLUSION

Use of RSB as an anesthetic management of umbilical herniorrhaphy is recommended only with anesthetic supplementation at the incision site.

Comparison of unilateral and bilateral spinal anesthesia with 2% hyperbaric prilocaine in day-case inguinal herniorrhaphy: a randomized controlled trial

BACKGROUND

Hyperbaric 2% prilocaine produces a faster onset and shorter duration of spinal anesthesia than a plain solution. The anesthetic profile could be improved by restricting the block to the operative side. We compared unilateral versus conventional bilateral spinal anesthesia with hyperbaric 2% prilocaine in day-case patients undergoing unilateral inguinal herniorrhaphy.

METHODS

Eighty patients were randomly assigned to receive either conventional bilateral (N.=40) or unilateral (N.=40) spinal anesthesia with 50 mg hyperbaric prilocaine 2%. In the unilateral group, lateral decubitus was maintained for 10 minutes. Sensory and motor block courses, time to first micturition, and side effects were recorded.

RESULTS

On the operated side, the highest sensory block was T8 (T12-T2) in the unilateral and T9 (T11-T4) in the bilateral group (P=0.0328); the time to motor (115 ± 26 min in the unilateral and 108 ± 24 min in the bilateral groups, P=0.2350) and sensory (156 ± 30 min in the unilateral and 158 ± 26 min in the bilateral groups, P=0.7550) block resolution was similar in both groups. On the non-operated side, the unilateral group had a faster motor (64 ± 48, P<0.001) and sensory (120 ± 47, P<0.001) time to block resolution than the conventional group. Restricted unilateral motor and sensory block was achieved in 30% and 12.5% of patients, respectively. Time to voiding was shorter in the unilateral than in the conventional group (220 ± 47 vs. 249 ± 51 min, respectively, P=0.0104). There were no significant differences in adequacy for surgery and side effects between the groups.

CONCLUSION

In day-case inguinal herniorrhaphy, attempting unilateral spinal anesthesia with 50 mg hyperbaric 2% prilocaine produced faster time to voiding.

A very early stage of obstructive fibrinous tracheal pseudo-membrane formation

As result of a short-term intubation (24 hours), we report a rare and poorly known complication: the formation of an obstructive fibrinous tracheal pseudo-membrane (OFTP). The diagnosis and therapy of OFTP were due to its spontaneous expectoration after a long asymptomatic time post extubation (four days): This is a very unusual event. A CT-scan of the chest performed 3 hours after intubation revealed the first step of pseudo-membrane developing.

Human TDE1, a TDE1/TMS family member, inhibits apoptosis in vitro and stimulates in vivo tumorigenesis

We have previously described hTDE1, the human homologue of the recently described TDE1/TMS family of proteins whose members have been identified in several species. Although a defined biochemical activity has yet to be assigned to TDE1/TMS family members, previous results point to the overexpression of family members in tumor cell lines or tissues. To define whether hTDE1 may directly impact on neoplastic transformation, we derived and characterized stable Rat-1 transfectants that constitutively express hTDE1 at the plasma membrane. Expression of hTDE1 in Rat-1 transfectants had a significant effect on cell contact inhibition in vitro as judged by a focus formation assay. In addition, by monitoring caspase-3 activity and Hoechst staining, we determined that hTDE1 overexpression partially protects cells from serum starvation- and etoposide-induced apoptosis. Finally, hTDE1 Rat-1-expressing clones accelerated the formation of tumors in a nude mouse assay. Our results suggest that hTDE1 contributes directly to oncogenesis in vivo that may in part be explained by its effect on apoptosis in vitro.

Microarray analysis of gene expression mirrors the biology of an ovarian cancer model

We have previously described an ovarian cancer model based on four independent spontaneously immortalized epithelial ovarian cancer cell lines (TOV-21G, TOV-81D, TOV-112D and OV-90) from patients who were never exposed to chemotherapy or radiation therapy. These cell lines are particularly interesting since they retain characteristics of the original epithelial ovarian cancers (EOC) from which they were derived. Here we report the characterization of this model system using high-density DNA microarrays in order to assess gene expression. Expression profiles were generated from total RNAs extracted from the four EOC cell lines. For comparison, expression profiling is also provided for a primary culture of normal ovarian surface epithelium (NOV-31) and a fresh EOC sample (TOV-578G). Comparison of expression profiles revealed patterns of expression that distinguish NOV-31 from that of all tumor derived samples. The expression pattern of TOV-81D, an EOC cell line that was derived from a patient with indolent disease, most closely resembles NOV-31 while profiles of samples derived from patients with more aggressive disease (TOV-21G, OV-90, TOV-112D and TOV-578G) showed more divergent patterns of expression. The microarray analysis (http://genome.mcgill.ca) results confirm the usefulness of an ovarian cancer model based on the characterization of these EOC cell lines.

Polyomavirus large T-antigen protects mouse cells from Fas-, TNF-alpha- and taxol-induced apoptosis

Polyomavirus large T-antigen (PyLT-Ag), a nucleophosphoprotein essential for regulating viral gene expression, modulates the cell cycle by binding to the Rb tumor suppressor gene product. PyLT-Ag/Rb binding is essential for in vitro immortalization. However, the effect of PyLT-Ag on apoptosis has not been extensively studied. We have previously reported that FasR agonist antibodies (FasR(Ab)) treatment of Sertoli cells derived from transgenic mice expressing PyLT-Ag induces the growth arrest of these cells without concomitant apoptosis. Here we show that stable expression of PyLT-Ag in murine Sertoli TM4 and hybridoma NSO cell lines confers protection from FasR(Ab)-induced apoptosis. The protection was maintained up to 48 h when cells were grown continuously in the presence of FasR(Ab). Removal of the death stimulus after 24 h exposure was sufficient to allow full recovery of the PyLT-Ag expressing cells. The protective effect conferred by PyLT-Ag was associated with a delay in the sequential activation of caspase-8 and -3 after FasR(Ab) treatment. PyLT-Ag co-precipitated following immunoprecipitation of caspase-8 or FADD, both components of the DISC. Based on these results we suggest that PyLT-Ag directly impedes the recruitment or activation of caspase-8 by the FasR. PyLT-Ag expression in TM4 cells was also associated with protection from TNF-alpha- and taxol-induced apoptosis. In contrast, PyLT-Ag expression was not sufficient to confer protection from captothecin-induced apoptosis. Taken together, these results indicate that PyLT-Ag can be a potent inhibitor of Fas(R)(Ab)-, TNF-alpha- and taxol-induced apoptosis.

The human TDE gene homologue: localization to 20q13.1-13.3 and variable expression in human tumor cell lines and tissue

Expression of the mouse testicular tumor differentially expressed (TDE) gene is increased in testicular tumors as well as in testicular tumor cell lines derived from transgenic mice carrying the polyomavirus large-T antigen under the control of the metallothionein-1 promoter. To determine whether the TDE gene has a role in the development of human cancers, we used the mouse TDE cDNA sequence to screen a human placental cDNA library. The human TDE cDNA homologue coded for a protein that was 78% homologous to the mouse TDE amino acid sequence. Like the mouse TDE protein, the human TDE protein had several predicted hydrophobic alpha-helices characteristic of transmembrane proteins. The human TDE gene was expressed in all cell lines and tissues examined. Four mRNA species were observed in placenta, where we identified an alternate splicing pattern and the use of two different polyadenylation sites. Using fluoresence in situ hybridization analysis, we localized the human TDE gene to the q13.1-13.3 region of chromosome 20, a region known to be amplified in several types of human cancers. We then observed, by northern blot analysis, that human TDE expression was increased in three of five lung tumors examined.

alpha 1-Antitrypsin (AAT) deficiency and ANCA-positive systemic vasculitis: genetic and clinical implications

A high incidence of alpha 1-antitrypsin (AAT) deficiency has been reported in patients with C-ANCA systemic vasculitis in association with antibodies against proteinase-3 (PR3). To clarify the role of AAT deficiency in the acute vasculitic process as well as in progression of the disease, we studied 84 patients with either C-ANCA or P-ANCA vasculitis with special reference to: (a) the AAT gene, (b) the phenotypic (Pi) variants and (c) the serum levels during both acute illness and remission. The PiZ gene was found in six patients (8% vs. 1.5% controls) irrespective of the type of autoantibodies (C-ANCA vs. P-ANCA). All PiZ patients displayed the ability to raise their AAT serum levels up to the normal range during acute illness. In contrast, 24 patients with the PiM phenotype presented low AAT serum levels during acute illness. In all these patients, the AAT levels returned to normal values during the remission. Low AAT levels were associated with low levels of C-reactive protein (PCR) (P < 0.001), with a less severe renal involvement or a minor risk of death, and, in one tested patient, with a novel point mutation (TCGA-->TCAA) at the enhancer-promoter region of the AAT gene. Low AAT serum levels did not correlate with either type/titre of autoantibody or distribution/severity of the vasculitis process. In the case-control study, high AAT levels emerged as a major determinant of progression towards end-stage renal failure [odds ratio 3 (95% CI 1.1-8.4)]. These results indicate: (a) a high incidence of the PiZ gene of AAT in systemic vasculitis irrespective of the type of autoantibodies; (b) a novel form of AAT deficiency associated with the normal PiM phenotype becoming manifest only during acute illness; (c) dysregulation of the acute-phase response affecting selectively AAT or both AAT and PCR; (d) correlation between low plasma levels of AAT and less severe renal involvement or risk of death.

The human skeletal muscle glycogenin gene: cDNA, tissue expression and chromosomal localization

Glycogen synthesis is impaired in first degree relatives of subjects with non-insulin-dependent diabetes mellitus and genes relevant to this metabolic pathway are considered reasonable candidates in the pathogenesis of the disease. In skeletal muscle the de novo synthesis of glycogen in primed by an enzyme named glycogenin. We have cloned the glycogenin cDNA from human skeletal muscle mRNA: human glucogenin is a 333 amino acid protein exhibiting 93% identity with rabbit glycogenin. A single transcript of about 2.4 kb, prominent in skeletal muscle, was detected by Northern blot analysis. In situ hybridization unequivocally located the human glycogenin gene to chromosome 3q25.1. Furthermore, we mapped two intronless glycogenin-related sequences to human chromosomes 12 and 13.

Cloning and characterization of a new human Xq13 gene, encoding a putative helicase

We describe the cloning and characterization of a new human Xq13 gene (XH2), extending over a 220 kb genomic stretch between MNK and DXS56. The gene, which undergoes X-inactivation, contains a 4 kb open reading frame and encodes a putative NTP-binding nuclear protein homologous to several members of the helicase II superfamily. The murine homologue maps to the syntenic genetic interval, between Pgk1 and Xist. In situ hybridization studies in mouse reveal precocious, widespread expression of the murine homologue of XH2 at early stages of embryogenesis, and more restricted expression during late developmental stages and at birth. XH2 is a new member of an expanding family of proven and putative helicases, sharing six conserved, collinear domains. In particular, the XH2 protein shows homology with yeast RAD54. Type II helicases have been implicated in nucleotide excision repair and the initiation of transcription. This new gene, represents a potential candidate for several genetic disorders mapped to human Xq13.