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The religious community of Jehovah's Witnesses holds that blood transfusion is against God's law. Therefore, surgical treatment of Jehovah's Witnesses is a great challenge for every surgeon, especially for cardiac surgeons because blood transfusion is frequently needed during such operations. In this study we summarize the experience with Jehovah's Witnesses who have undergone open-heart surgery in Debrecen from 1989 to 1999 due to various cardiac diseases. Applying a complex surgical procedure developed by the authors to minimize blood loss during operation, preserved blood products were omitted. Three patients out of twenty-four died during the postoperative period. The twenty-one longtime survivors showed significant improvement in their clinical stage during the mean follow up of 37.6 months. More and more operations are done successfully without blood or preserved blood products worldwide, so it could be said that nowadays surgical treatment of Jehovah's Witnesses has a lower risk than before. [ABSTRACT FROM AUTHOR]

Background: Lactating women undergoing operations under general anesthesia are advised to pump and discard their milk for 24h after the procedure. We determined the kinetics of midazolam elimination in breast milk to ascertain its safety after midazolam administration.Methods: Five lactating women were studied after providing institutionally-approved written informed consent. Patients were premedicated with midazolam, 2 mg IV, 5 min before anesthetic induction with fentanyl, 100 μg IV, and propofol, 2.5 mg/kg IV. Anesthesia was maintained with potent volatile anesthetics. Milk was collected using an electric breast pump before and at 5, 7, 9, 11, and 24h after drug administration. Blood samples were collected before and at regular intervals up to 7h after drug administration. Plasma and milk midazolam concentrations were measured by LC-MS. Midazolam elimination in milk was modelled simultaneously with the plasma kinetics as the cumulative amount of drug in milk just as urinary elimination is modelled, albeit with a delay.Results: Plasma midazolam pharmacokinetics were consistent with those reported by ourselves and others. In 24h of milk collection, only 0.005 (± 0.005)% of the midazolam dose was eliminated in milk, representing 0.009 (± 0.005)% of the midazolam elimination clearance with a pharmacokinetic delay of approximately 9h.Conclusion: The amount of midazolam appearing in breast milk over 24h after administering a single dose is very small and unlikely to affect a healthy term infant.Clinical Pharmacology & Therapeutics (2005) 79, P7–P7; doi: 10.1016/j.clpt.2005.12.021 [ABSTRACT FROM AUTHOR]

While Title VI of the Civil Rights Act of 1964 mandates use of interpreters for patients with limited English proficiency, significant disparities persist in intensive postsurgical care. We present the case of a 60-year-old Vietnamese-speaking man with a Type A aortic dissection requiring postoperative mechanical ventilation and stroke care. Despite use of a remote video interpreter, our language-discordant nursing and physician providers faced challenges in managing agitation and delirium and assessing neurological function. This case highlights the need for adequate interpretation equipment, linguistic diversity among providers, and interventions to promote and enable consistent certified and professional medical interpreter use., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 International Anesthesia Research Society.)

Objective: The aim of this work is to formulate recommendations based on global expert consensus to guide the surgical community on the safe resumption of surgical and endoscopic activities., Background: The COVID-19 pandemic has caused marked disruptions in the delivery of surgical care worldwide. A thoughtful, structured approach to resuming surgical services is necessary as the impact of COVID-19 becomes better controlled. The Coronavirus Global Surgical Collaborative sought to formulate, through rigorous scientific methodology, consensus-based recommendations in collaboration with a multidisciplinary group of international experts and policymakers., Methods: Recommendations were developed following a Delphi process. Domain topics were formulated and subsequently subdivided into questions pertinent to different aspects of surgical care in the COVID-19 crisis. Forty-four experts from 15 countries across 4 continents drafted statements based on the specific questions. Anonymous Delphi voting on the statements was performed in 2 rounds, as well as in a telepresence meeting., Results: One hundred statements were formulated across 10 domains. The statements addressed terminology, impact on procedural services, patient/staff safety, managing a backlog of surgeries, methods to restart and sustain surgical services, education, and research. Eighty-three of the statements were approved during the first round of Delphi voting, and 11 during the second round. A final telepresence meeting and discussion yielded acceptance of 5 other statements., Conclusions: The Delphi process resulted in 99 recommendations. These consensus statements provide expert guidance, based on scientific methodology, for the safe resumption of surgical activities during the COVID-19 pandemic., Competing Interests: The authors report no conflicts of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

The aim of this study was to assess the effect of a dynamic electronic cognitive aid with embedded clinical decision support (dCA) versus a static cognitive aid (sCA) tool. Anesthesia residents in clinical anesthesia years 2 and 3 were recruited to participate. Each subject was randomized to one of two groups and performed an identical simulated clinical scenario. The primary outcome was task checklist performance with a secondary outcome of performance using the Anesthesia Non-technical skills (ANTS) scoring system. 34 residents were recruited to participate in the study. 19 residents were randomized to the sCA group and 15 to the dCA group. Overall inter-rater agreement for total checklist, malignant hyperthermia, hyperkalemia and ventricular fibrillation was 98.9%, 97.8%, 99.5% and 99.5% respectively with similar Kappa coefficient. Inter-rater agreement for ANTS partial ratings, however, was only 53.5% with a similar Kappa of 0.15. Mean performance was statistically higher in the dCA group versus the sCA group for total check list performance (15.70 ± 1.93 vs 12.95 ± 2.16, p < 0.0001). The difference in performance between dCA and sCA is most notable in dose-dependent related checklist items (4.60 ± 1.3 vs 1.89 ± 1.23, p < 0.0001), while the performance score for dose-independent checklist items was similar between the two groups (p = 0.8908). ANTS ratings did not differ between groups. In conclusion, we evaluated the use of a sCA versus a dCA with embedded decision support in a simulated environment. The dCA group was found to perform more checklist items correctly.Clinical Trial Registration: Clinicaltrials.gov study #: NCT02440607.

In this study, we examined anesthetic records before and after the implementation of an electronic anesthetic record documentation (AIMS) in a single surgical population. The purpose of this study was to identify any inconsistencies in anesthetic care based on handwritten documentation (paper) or AIMS. We hypothesized that the type of anesthetic record (paper or AIMS) would lead to differences in the documentation and management of hypotension. Consecutive patients who underwent esophageal surgery between 2009 and 2014 by a single surgeon were eligible for the study. Patients were grouped in to 'paper' or 'AIMS' based on the type of anesthetic record identified in the chart. Pertinent patient identifiers were removed and data collated after collection. Predetermined preoperative and intraoperative data variables were reviewed. Consecutive esophageal surgery patients (N = 189) between 2009 and 2014 were evaluated. 92 patients had an anesthetic record documented on paper and 97 using AIMS. The median number of unique blood pressure recordings was lower in the AIMS group (median (Q1,Q3) AIMS 30.0 (24.0, 39.0) vs. Paper 35.0 (28.5, 43.5), p < 0.01). However, the median number of hypotensive events (HTEs) was higher in the AIMS group (median (Q1,Q3) 8.0 (4.0, 18.0) vs. 4.0 (1.0, 10.5), p < 0.001), and the percentage of HTEs per blood pressure recording was higher in the AIMS group (30.4 ((Q1, Q3) (9.5, 60.9)% vs. 12.5 (2.4, 27.5)%), p < 0.01). Multivariable regression analysis identified independent predictors of HTEs. The incidence of HTEs was found to increase with AIMS (IRR = 1.88, p < 0.01). Preoperative systolic blood pressure, increased blood loss, and phenylephrine. A phenylephrine infusion was negatively associated with hypotensive events (IRR = 0.99, p = 0.03). We noted an increased incidence of HTEs associated with the institution of an AIMS. Despite this increase, no change in medical therapy for hypotension was seen. AIMS did not appear to have an effect on the management of intraoperative hypotension in this patient population.

Purpose: Previous studies have found that most cerebral oximeters are subject to inaccuracies secondary to extracranial contamination of the cerebral oximetric signals. We hypothesized that the more advanced second-generation FORE-SIGHT ELITE cerebral oximeter would be significantly less affected by extracranial tissue hypoxemia than the more widely used first-generation INVOS™ 5100C monitor., Methods: Twenty healthy volunteers aged 18-45 yr had the INVOS and FORE-SIGHT probes placed on their forehead in a random sequence while in the supine position. A pneumatic head cuff was then placed around each volunteer's head just below both the oximeter and a concomitantly placed scalp forehead pulse oximeter probe. The subjects' scalp cerebral oxygen saturation (SctO2) values were measured and compared using the two different devices in sequence, both before and after scalp tissue ischemia was induced by the pneumatic cuff., Results: Extracranial ischemia resulted in a significant reduction in SctO2 values from baseline in both devices. The INVOS 5100C recorded a median [interquartile range] decrease in SctO2 from baseline at five minutes of 15.1% [12.6 - 17.6], while that recorded by the FORESIGHT ELITE device was 8.6% [4.0 -12.3] at five minutes (median difference, 7.9%; 99% confidence interval, 1.9 to 16.5; P = 0.002)., Conclusion: Updated technological algorithms employed in the FORE-SIGHT ELITE cerebral oximeter may be responsible for less extracranial contamination than was observed in the previous-generation INVOS 5100C device. The impact that this extracranial contamination may have on the clinical use of these devices remains to be determined.

We announce the completion of the genome sequence of a phenol derivative-degrading bacterium, Rhodococcus erythropolis strain CCM2595. This bacterium is interesting in the context of bioremediation for its capability to degrade phenol, catechol, resorcinol, hydroxybenzoate, hydroquinone, p-chlorophenol, p-nitrophenol, pyrimidines, and sterols.

Background: Myocardial ischemia is the most common cause of congestive heart failure. Angiogenic therapy has recently been demonstrated to enhance myocardial perfusion in the ischemic setting. We therefore hypothesized that administration of adenovirus encoding for vascular endothelial growth factor could be used to enhance myocardial function in a pacing-induced model of heart failure., Methods: Yorkshire swine underwent a left thoracotomy with placement of a ventricular epicardial pacing system. Animals received adenovirus coding either for the 121-amino-acid isoform of vascular endothelial growth factor (Ad(CU)VEGF121.1 group, n = 8) or a null vector coding for no genes (AdNull group, n = 8). The adenovirus was administered in the left ventricular free wall as 10 transepicardial injections of 100 microL each (total dose of 10(11) particle units). After a 1-week recovery period, animals were paced at a rate of 230 beats/min for 7 days to induce heart failure. Transthoracic echocardiographic and sonomicrometric measurements were performed before pacing (baseline), on termination of pacing (day 0), and then weekly for 3 weeks., Results: The fractional area change was significantly decreased in AdNull animals at day 0 after pacing compared with the Ad(CU)VEGF121.1 animals (29% +/- 14% vs 46% +/- 8%, P =.02). The fractional area change recovered to baseline values within 7 days in the Ad(CU)VEGF121.1 animals (62% +/- 7%) but remained significantly impaired in the AdNull group compared with that in the Ad(CU)VEGF121.1 animals up to day 21 (P =.04). Similarly, fractional wall thickening demonstrated a decrease at day 0 after pacing that was greater (P <.05) in the AdNull group compared with that in the Ad(CU)VEGF121.1 group in 5 of 6 segments. Fractional wall thickening returned to levels approximating prepacing values in all segments within 7 days in the Ad(CU)VEGF121.1 group but remained significantly impaired compared with prepacing fractional wall thickening (P <.05) in the AdNull group in 5 of 6 segments up to day 21 after pacing. Segmental shortening, as measured by sonomicrometry, also was significantly decreased at day 7 in the AdNull group compared with that in the Ad(CU)VEGF121.1 group (10% +/- 4% vs 16% +/- 3%, P =.004) and remained significantly impaired (P <.05) in the AdNull group at day 14 and 21 when compared with baseline values., Conclusion: Preservation of cardiac performance and a more rapid recovery of myocardial function can be achieved in a model of pacing-induced cardiomyopathy with adenovirus-mediated administration of vascular endothelial growth factor compared with that seen in a null virus control group. These data suggest that angiogenic therapy may be useful clinically in treating cardiomyopathy.

Anxiety, agitation, delirium, and pain are common findings in the ICU. These unhealthy states may lead to increased irritability, discomfort, hypertension, tachycardia, cardiac ischemia, harmful motor activity, and psychologic disquiet for the patient. The appropriate treatment of these conditions may lead to decreased morbidity and mortality in the critically ill patient. Unfortunately, the management of anxiety, agitation, delirium, and pain in the intensive care unit is not ideal. Many patients interviewed after an ICU stay rate their pain control as poor and their memories of their stay as unpleasant. Furthermore, many caregivers lack sufficient understanding of the appropriate or indicated uses of drugs to allay patients' fears and pain. The use of suitable protocols for the proper titration of sedation of mechanically ventilated patients and monitoring of the level of sedation in ventilated patients may decrease the amount of time that patients are ventilated and may alleviate some of the emotional stresses of recall of painful procedures or uncomfortable mechanical ventilation. Future research into protocols for the care of the critically ill patient can enhance the overall well-being of these patients.

Objective: To investigate the effect of a single, vital capacity breath (vital capacity maneuver [VCM]), administered at the end of cardiopulmonary bypass (CPB), on pulmonary gas exchange in patients undergoing coronary artery bypass graft surgery., Design: Prospective, randomized, double-blind study., Setting: University-affiliated hospital., Participants: Forty patients scheduled for elective coronary artery bypass graft surgery and early tracheal extubation., Interventions: Patients were randomized to 1 of 2 groups. VCM patients received a VCM at the conclusion of CPB. Control patients received no VCM., Measurements and Main Results: Intrapulmonary shunt (Q(S)/Q(T)), arterial oxygenation (PaO2), and alveolar-arterial oxygen gradients (P(A-a)O2) were measured after induction of anesthesia, CPB, intensive care unit (ICU) arrival, and extubation. The duration of postoperative intubation was recorded for each group. Q(S)/Q(T) increased significantly 30 minutes after CPB in the control group (15.7 +/- 1.8% to 27.4 +/- 2.6%; p = 0.01). In the VCM group, a small decrease in Q(S)/Q(T) occurred (16.1 +/- 2.0% to 14.9 +/- 2.0%). After ICU arrival and extubation, no significant difference in Q(S)/Q(T) existed between the 2 groups. With the exception of a higher P(A-a)O2 in the control group at induction of anesthesia, no differences in PaO2 or P(A-a)O2 were present between the 2 groups at any measurement interval. Patients who received a VCM were extubated earlier than the control group (6.5 +/- 2.1 hours v 9.4 +/- 4.2 hours; p = 0.01)., Conclusion: The use of a VCM prevented an increase in Q(S)/Q(T) from occurring in the operating room. Although a VCM did not influence pulmonary gas exchange in the ICU, its application in the operating room appears to exert a beneficial effect on tracheal extubation times after cardiac surgery., (Copyright 2001 by W.B. Saunders Company.)

In the practice of forensic medicine, we find many of cases of death where the actual cause is not determinable with autopsy, histological or toxicological examinations. In these cases of death, we can consider cardiac dysfunction of unknown origin, in the background of which such a physiologic cardiac insufficiency occurs that cannot be detected with the previously mentioned methods. The dysfunction is possibly associated with a significant change in certain inorganic elements, primarily in the conduction system of the heart. In the absence of published data, our goal was to determine the concentration of inorganic elements in the specialized rhythm determining muscle cell groups in the heart: sinus node (SN), atrioventricular node (AV), septum (SE), left ventricle anterior wall (LVAW). With microwave technology we destroyed the muscle tissue and measured the concentration of ions (Na, Mg, K, Ca, Mn, Fe, Cu, Zn, P, S) using Inductive Completed Plasma Atom Emission Spectrometry (ICP-AES) equipment. Of the 24 cases examined, the average ion concentrations in microgram/g were the following; Sinus: Na 2602 +/- 493, Mg 120 +/- 24, K 1787 +/- 347, Ca 244 +/- 41, Mn 0.129 +/- 0.011, Fe 58 +/- 12, Cu 2.171 +/- 0.46, Zn 10.4 +/- 2.027, P 1147 +/- 227, S 2301 +/- 245; Septum: Na 1452 +/- 315, Mg 243 +/- 56, K 3269 +/- 689, Ca 105 +/- 26, Mn 0.17 +/- 0.05, Fe 74 +/- 16, Cu 3.557 +/- 0.952, Zn 25.75 +/- 8.4, P 2764 +/- 494, S 3001 +/- 523; Av: Na 2614 +/- 517, Mg 242 +/- 40.2, K 2010 +/- 395, Ca 271 +/- 27.3, Mn 0.13 +/- 0.029, Fe 54 +/- 12, Cu 2.369 +/- 0.297, Zn 15 +/- 3.2, P 1625 +/- 291, S 2535 +/- 346; Lvaw: Na 1340 +/- 201, Mg 250 +/- 37, K 3659 +/- 532, Ca 88 +/- 22, Mn 0.175 +/- 0.05, Fe 76 +/- 19, Cu 3.62 +/- 0.58, Zn 27.13 +/- 3.1, P 3025 +/- 441, S 3140 +/- 440.

Background and Objectives: Unintentional dural puncture with a Tuohy epidural needle during the course of an epidural anesthetic may lead to a postdural puncture headache and double vision. We describe a parturient that developed left abducens nerve palsy after an epidural anesthetic for labor., Methods: A 32-year-old female developed a postdural puncture headache 1 day after an epidural anesthetic for labor. Over the next several days she began to complain of diplopia. Subsequent to this, she developed lateral rectus muscle palsy., Results: The lateral rectus palsy resolved spontaneously 8 weeks after the epidural anesthetic., Conclusions: We believe that a dural puncture during an attempted epidural anesthetic resulted in cerebrospinal fluid (CSF) leakage with a consequent headache. The CSF leak caused traction on the sixth cranial nerve resulting in lateral rectus muscle palsy. An epidural blood patch performed after the onset of symptoms did not acutely resolve the abducens nerve palsy.