Use of an automated anesthesia information system to determine reference limits for vital signs during cesarean section

INTRODUCTION

We evaluated whether automated anesthesia information systems can be used to calculate reference limits (population-based "normal values") for vital signs. We considered four populations of women undergoing cesarean section: healthy under spinal anesthesia, healthy under general anesthesia, pre-eclamptic/eclamptic under spinal anesthesia, and pre-eclamptic/eclamptic under general anesthesia.

METHODS

Reference limits were calculated for each of the study populations by determination of percentiles for: minimum heart rate, maximum heart rate, minimum arterial oxyhemoglobin saturation (SaO2), minimum mean arterial pressure (MAP), maximum MAP, decrease in MAP, and increase in MAP.

RESULTS

There was one adverse anesthetic outcome among the 1,300 women in the study; the woman sustained a post-dural puncture headache. The 5th percentiles of SaO2 were at least 95% saturation under spinal versus 90% under general. Under spinal anesthesia, 95th percentiles for decreases in MAP from baseline were 63 mmHg for healthy and 75 mmHg for pre-eclamptic/eclamptic women. Under general anesthesia, the 95th percentiles for maximum MAP were 161 and 177 mmHg, respectively. Two women of the 1,300 patients experienced simultaneously a minimum SaO2 < 92% and minimum MAP < 50 mmHg.

DISCUSSION

Automated anesthesia information systems can be used to determine reference limits for vital signs during anesthesia. Reference limits may play a role in malpractice cases when an expert claims that care by an anesthesiologist was sub-standard as shown by vital signs that were not maintained within the normal range during the critical portions of an anesthetic. Automated anesthesia information systems may enhance expert witnesses' clinical judgment.

Comparison of synovial fluid cartilage marker concentrations and chondral damage assessed arthroscopically in acute knee injury

OBJECTIVE

To examine the correlation between synovial fluid cartilage markers and degree of cartilage damage determined by arthroscopic evaluation in subjects with acute knee injury.

DESIGN

Chondral damage was quantified using a validated arthroscopic scoring system in 20 subjects with effusive acute knee injuries of less then 4 months duration and no history or radiographic evidence of joint pathology. Levels of synovial fluid 3B3(-) neoepitope, 3B3(+) chondroitinase generated epitope of proteoglycan, keratan sulfate (KS) and hyaluronic acid (HA) were measured by competitive enzyme-linked immunosorbent assays using monoclonal antibodies 3B3 and 5D4. Total sulfated glycosaminoglycan (GAG) was measured by 1,9-dimethylmethylene blue colorimetric dye-binding assay.

RESULTS

We found a dramatic decrease in levels of 3B3(-) (rs = -0.62, P = 0.004), and GAG (rs = -0.49, P = 0.03) with increasing chondral damage score; but no correlation of damage score with 3B3(+), KS or HA levels.

CONCLUSION

These data reveal a change in cartilage metabolism within the first 4 months of symptomatic knee injury evinced by a significant inverse correlation of 3B3(-) and GAG levels to chondral lesion severity. These results suggest that serial measurement of these synovial fluid markers in the setting of acute knee injury could predict chondral lesion severity and aid in the decision to intervene surgically.

Hysterosalpingography, laparoscopy and hysteroscopy in infertility. A comparative study

The accuracy and significance of hysterosalpingography (HSG) during an infertility evaluation were assessed by comparing the radiologic findings on HSG to the operative findings during laparoscopy and hysteroscopy. One hundred ninety-three patients underwent a complete infertility evaluation at our center. HSG was performed during the proliferative phase and was followed by laparoscopy and hysteroscopy, when indicated, during the same or next cycle. False-positive findings on HSG were noted in 5.1% of the patients. In 21%, adnexal adhesions and pelvic endometriosis were identified during surgery in spite of normal HSG. HSG is as accurate as laparoscopy in the diagnosis of tubal disease. However, laparoscopy excels HSG in the diagnosis of pelvic pathology. HSG should remain an integral part of the female infertility investigation and must be performed before laparoscopy and hysteroscopy.

Transdermal viprostol in the treatment of male pattern baldness

Fifty-seven men were randomly assigned for treatment of androgenetic alopecia with viprostol, vehicle, or placebo twice daily for 24 weeks. Nonvellus hair growth was assessed subjectively by both patient and investigator and objectively through hair counts from macrophotographs of the target area. Nonvellus target area hair counts declined in all three treatment groups at the end of the 6-month study. Viprostol is not an effective hair growth promoter in androgenetic alopecia.

A controlled trial of two low-dose heparin regimens for the prevention of postoperative deep vein thrombosis

Venous thromboembolism is a serious complication following gynecologic surgery and is particularly common in patients with malignancy. A previous study of subcutaneous low-dose heparin given as one dose preoperatively and every 12 hours postoperatively failed to show a benefit in gynecologic oncology patients. In the present study, two more intense regimens of low-dose heparin were evaluated. Three hundred four patients were assigned randomly to receive no prophylaxis (controls), subcutaneous heparin 5000 units 2 hours before surgery and every 8 hours postoperatively (low-dose heparin) (regimen I), or 5000 units heparin subcutaneously every 8 hours preoperatively (between two and nine doses) and every 8 hours postoperatively (regimen II). All patients had thromboembolism surveillance with the fibrinogen uptake test and clinical evaluation. Eighty-four percent had a malignancy. Thromboemboli were diagnosed in 19 of 103 control patients, ten of 104 regimen I patients, and six of 97 regimen II patients, a statistically significant difference (P less than .008). When compared with the control group, the study groups had no evidence of increased bleeding complications or alteration of laboratory coagulation indicators.

Effect of daily charge feedback on inpatient charges and physician knowledge and behavior

Concurrent charge feedback has gained widespread acceptance as a method of minimizing hospitals' losses under the Medicare prospective payment system despite the fact that its effect on patient outcomes, physician behavior, or charges has not been studied in depth. In a controlled trial on two medical wards in an academic medical center, the effect of daily charge feedback on charges was studied. Sixty-eight house staff and 16 teaching attending physicians participated during a 35-week period, taking care of 1057 eligible patients. No significant differences in charges were seen when all patients were included. Since 45% of patients had planned protocol admissions (diagnostic workups or protocol treatment) on which the house staff had little change to impact, a subgroup analysis was performed, excluding these patients. In the remaining patients, a highly significant reduction in mean total charges (17%), length of stay (18%), room charges (18%), and diagnostic testing (20%) was found. In-hospital mortality and preventable readmission within 30 days were similar on the two wards. It was concluded that charge feedback alone is effective in a teaching hospital for decreasing charges.

Prognosis of patients with cirrhosis and chronic liver disease admitted to the medical intensive care unit

Patients with hepatic failure admitted to the medical ICU (MICU) generally have a poor prognosis. To determine if there were readily identifiable clinical factors associated with a high predictive value for outcome, we reviewed retrospectively the charts of 100 patients with serious liver disease admitted to the MICU. The overall mortality of the group was 64%. We found that Child's class, a need for mechanical ventilation, and an elevated serum creatinine had the greatest prognostic significance. Ninety-one percent of the patients receiving assisted ventilation, 89% of the patients in Child's class C, and 93% of the patients with creatinine values greater than 1.3 mg/dl died during their MICU admission. Furthermore, a multivariant regression analysis indicated that patients in Child's class C receiving mechanical ventilation who had an abnormal serum creatinine (greater than 1.3 mg/dl) during the first 72 h in the MICU had only a 2% survival rate.

Double-blind, placebo-controlled trial of potassium chloride in the treatment of mild hypertension

Epidemiological and experimental data suggest blood pressure-lowering effects of dietary potassium. A randomized, double-blind clinical trial was used to assess blood pressure response to orally administered potassium, 120 mEq/day, and to placebo in 101 adults with mild hypertension. Blood pressure was measured with a random-zero sphygmomanometer every 2 weeks of this 8-week trial. Systolic blood pressure in the potassium-treated group decreased by 6.4 +/- 13.7 (SD) mm Hg (p less than or equal to 0.025) compared with 0.11 +/- 13.0 mm Hg in the placebo-treated group (p = 0.96). Diastolic blood pressure in the potassium-treated group decreased by 4.1 +/- 8.3 mm Hg (p less than or equal to 0.05) compared with a 1.6 +/- 6.5 mm Hg decrease in placebo-treated subjects (p = 0.09). Baseline blood pressure of potassium-treated subjects was unexpectedly higher than that of controls. After correcting for baseline variation, blood pressure still decreased 3.4/1.8 mm Hg more in potassium recipients than in placebo recipients (p = 0.14 and 0.24, respectively). Blood pressure decreased by 19/13 mm Hg in five blacks taking potassium versus a 1/0 mm Hg increase in seven blacks taking placebo. Compliance with the potassium regimen was 91.5% by pill count; only one subject discontinued treatment because of side effects. In conclusion, 120 mEq/day of microencapsulated potassium chloride was well tolerated in adults with mild hypertension. An antihypertensive effect of potassium cannot be ruled out despite the fact that there was no statistically significant difference between potassium-treated and placebo-treated subjects after adjustment for differences in baseline blood pressure.(ABSTRACT TRUNCATED AT 250 WORDS)

Articulation development in children with cleft lip/palate

This longitudinal study analyzed the articulation development of 108 children with cleft lip/palate from three through eight years of age. The data suggest that as the severity of clefting increases the severity of the articulation deficit does also. Age and type of cleft were statistically significant factors in the development of normal articulation skills. Children with cleft lip appeared to be a homogeneous speaking group characterized by normal articulation development. However, children with palatal clefts remained at a heterogeneous group with regard to their articulation test performance through eight years of age. Future comparisons of articulatory proficient and articulatory deficient cleft palate children may shed light in morphological and other reasons for the articulation deficiency in some children.