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There have been numerous reports studying the effect of neuraxial analgesia on breastfeeding success, but the results are inconsistent. We performed a literature search in various databases for studies comparing neuraxial analgesia to non-neuraxial or no analgesia. Outcomes were the percentage of women breastfeeding fully or mixed with formula. Where possible, nulliparous parturients were analyzed separately. We conducted an analysis excluding studies of serious and critical risk of bias. Odds ratios and 95% confidence intervals were calculated. We included 15 studies (13 observational studies, 1 secondary analysis of a randomized controlled trial, 1 case-control study) with 16,112 participants. Overall, there were 6 studies that found no difference between groups, 6 studies that showed a significantly lower incidence of breastfeeding in the neuraxial group and 3 studies finding mixed results (at some time-points statistically significant and at some time-point statistically non-significant results). In nulliparous only studies, 2 found no difference between study groups, 1 found a lower breastfeeding rate in the neuraxial group and 3 studies showed mixed results. Excluding studies with a serious and critical risk of bias, 1 study found no difference between study groups, 3 studies found a decrease of breastfeeding rates in the neuraxial group, and 1 study showed mixed results. In our review we found a high disparity in results. One reason is probably the high potential of confounding (immediate skin to skin placement, maternity leave etc.). Education programs and breastfeeding support are likely more important in determining long term breastfeeding success. •The relationship between neuraxial labour analgesia and breastfeeding has been frequently studied•After performing a systematic review we found heterogenous results•Studies did not control for confounding factors and therefore more studies need to be performed

Background Aiming to clarify the mechanism of weight loss after the restrictive bariatric procedure of sleeve gastrectomy (LSG), the volumes and pressures of the stomach, of the removed part, and of the remaining sleeve were measured in 20 morbidly obese patients. Methods The technique used consisted of occlusion of the pylorus with a laparoscopic clamp and of the gastroesophageal junction with a special orogastric tube connected to a manometer. Instillation of methylene-blue-colored saline via the tube was continued until the intraluminal pressure increased sharply, or the inflated stomach reached 2,000 cc. After recording of measurements, LSG was performed. Results Mean volume of the entire stomach was 1,553 cc (600–2,000 cc) and that of the sleeve 129 cc (90–220 cc), i.e., 10% (4–17%) and that of the removed stomach was 795 cc (400–1,500 cc). The mean basal intragastric pressure of the whole stomach after insufflations of the abdominal cavity with CO 2 to 15 mmHg was 19 mmHg (11–26 mmHg); after occlusion and filling with saline it was 34 mmHg (21–45 mmHg). In the sleeved stomach, mean basal pressure was similar 18 mmHg (6–28 mmHg); when filled with saline, pressure rose to 43 mmHg (32–58 mmHg). The removed stomach had a mean pressure of 26 mmHg (12–47 mmHg). There were no postoperative complications and no mortality. Conclusions The notably higher pressure in the sleeve, reflecting its markedly lesser distensibility compared to that of the whole stomach and of the removed fundus, indicates that this may be an important element in the mechanism of weight loss.

Every anesthesiologist who performed an ADP while performing a labor epidural was asked to complete an anonymous questionnaire within 24 hours, and report parturient pain (Verbal Numeric Score 0–10), assess parturient cooperation (yes/no), detail delivery room conditions (staff physically supporting woman with positioning, location of support staff), self-reported fatigue (0=not tired 10=most tired), self-reported stress (yes/no), purported reason for both self-reported stress and purported reason ADP occurred. Most dural punctures were performed by intermediate level residents.Table 1 Parturient cooperation, delivery room conditions and subjective responses on why ADP occurred Domain Factor N (%) Median (IQR) Parturient Median parturient pain 6 (3.5–8) Parturient cooperated during procedure Yes-198 (78.0%) No-54 (21.3%) Unanswered -2 (0.8%) Organizational Parturient physically supported during procedure Yes-154 (60.6%) No-100 (39.4%) Placement of nurse/obstetrician during procedure Physically supporting parturient-154 (60.6%) Present but not near parturient-58 (22.9%) Not in room-42 (16.5%) Task Feeling of stress when performing the epidural Yes-48 (18.9%) No- 206(81.1%) Reasons for self reported stress Inability to feel landmarks-6 (12.5%) Tiredness-3 (6.25%) Inability to properly communicate with patient-3 (6.25%) Stress from having people watch them-2 (4.1%) Inexperience-2 (4.1%) Use personal protective equipment-1 (2.1%) Need to go to the bathroom-1 (2.1%) Immediate previous dural puncture-1 (2.1%) Purported reason for ADP Strange loss of resistance-85 (33.5%) Small distance to epidural-28 (11%) Hard ligamentum flavum-21 (8.3%) Patient movement 44 (17.3%) Other causes-28 (11%) Did not know-48 (18.9%) Position epidural performed Sitting position-216 (85%) Lateral position-37 (14.6%) (Unanswered-2 f orms) Loss of resistance modality Air-69 (27.2%) Saline-160 (63%) Combination-23 (9.1%) (Unanswered two forms) Ultrasound used for prescanning Yes-2 (0.8%) No-252 (99.2%) Time of day procedure performed Morning shift-88 (34.6) Evening shift-64 (25.2%) Night shift- 102 (40.2%) Operator factors Self reported tiredness 4 (2–7) Residency level First year resident-68 (26.8%) Second year resident-109 (42.9%) Third year resident-35 (13.8%) Fellows/attendings-42 (16.5%) Epidural experience 0–100–64 (25.2%) 101–500–98 (38%) 501–1000–33 (13.0%) >1001–59 (22.8%) ADP, accidental dural puncture. [...]our survey results do support the notion that improving patient cooperation would be an attractive target for quality improvement.

Background In recent years, laparoscopic sleeve gastrectomy (LSG) as a single-stage procedure for the treatment of morbid obesity is becoming increasingly popular. Of continuing concern are the rate of postoperative complications and the lack of consensus as to surgical technique. Methods A prospective study assessment was made of 120 consecutive morbidly obese patients with body mass index (BMI) of 43 ± 5 (30 to 63), who underwent LSG using the following technique: (1) division of the vascular supply of the greater gastric curvature and application of the linear stapler-cutter device beginning at 6–7 cm from the pylorus so that part of the antrum remains; (2) inversion of the staple line by placement of a seroserosal continuous suture close to the staple line; (3) use of a 48 Fr bougie so as to avoid possible stricture; (4) firing of the stapler parallel to the bougie to make the sleeve as narrow as possible and prevent segmental dilatation. Results Intraoperative difficulties were encountered in four patients. There were no postoperative complications—no hemorrhage from the staple line, no anastomotic leakage or stricture, and no mortality. In 20 patients prior to the sleeve procedure, a gastric band was removed. During a median follow-up of 11.7 months (range 2–31 months), percent of excess BMI lost reached 53 ± 24% and the BMI decreased from 43 ± 5 to 34 ± 5 kg/m 2 . Patient satisfaction scoring (1–4) at least 1 year after surgery was 3.6 ± 0.8. Conclusions The good early results obtained with the above-outlined surgical technique in 120 consecutive patients undergoing LSG indicate that it is a safe and effective procedure for morbid obesity. However, long-term results are still pending.

To compare patient-controlled analgesia (PCA) with tramadol with PCA with remifentanil in second trimester abortion. Prospective, randomized double-blinded study University-affiliated medical center. 30 ASA physical status 1 and 2 patients undergoing a second trimester abortion. Patients received PCA with either tramadol or remifentanil. Analgesia was initiated in the tramadol group by an initial loading dose of tramadol 1.0 mg/kg with 10 mg of metoclopramide followed by a PCA bolus of 0.3 mg/kg/mL of tramadol every 5 minutes. For remifentanil, which does not require a loading dose, a placebo of 100 mL of 0.9% normal saline was given followed by PCA of 0.4 μg/kg/mL every two minutes. Women were evaluated for pain via verbal analog score (VAS; 0-100), sedation, nausea, blood pressure, pulse, and respiratory rate. On the day of discharge, women were analyzed for overall satisfaction. Primary outcome was pain scores and general satisfaction. Analysis by time yielded no statistically significant difference in VAS scores between the groups at any point except 16-20 hours after induction of labor, when pain was lower in the tramadol group (11.3 ± 18.1 vs. 36.7 ± 27.4; P = 0.04). The average VAS score was low in both groups, with no significant differences noted between groups (P = 0.74). Satisfaction scores were high in both groups, with no significant differences noted between them (P = 0.89). Both drugs are acceptable choices for pain control in patients undergoing second trimester abortions.

BACKGROUND: Nitroglycerin (NTG) has been shown to be a useful adjunct for pain treatment without increasing adverse side effects. The effects of NTG on postoperative morphine consumption after knee replacement were evaluated. METHODS: After undergoing total knee replacement, patients receiving patient‐controlled morphine analgesia were randomly assigned to receive either an NTG or a placebo patch. The blinded investigator assessed each patient using a visual analogue scale at rest and while moving, as well as the patient’s morphine requirements, sedation score, sleep quality, nausea and vomiting, vital signs and postoperative bleeding. RESULTS: Two of the patients in the NTG group suffered postoperative myocardial infarctions after removal of the patch. Because of these two serious adverse effects, the study was stopped prematurely. In the subset of patients studied, NTG conferred no advantage over placebo in pain control (visual analogue scale at rest or during movement) and in satisfaction scores. CONCLUSIONS: The use of NTG patches conferred no advantage over the use of placebo in patients receiving patient‐controlled morphine analgesia after total knee replacement. Two myocardial infarcts occurred in this group. Therefore, the safety of postoperative NTG patch use for pain control must be questioned.

Paraplegia is an uncommon yet devastating complication following thoracotomy, usually caused by compression or ischemia of the spinal cord. Ischemia without compression may be a result of global ischemia, vascular injury and other causes. Epidural anesthesia has been implicated as a major cause. This report highlights the fact that perioperative cord ischemia and paraplegia may be unrelated to epidural intervention. A 71-yr-old woman was admitted for a left upper lobectomy for resection of a non-small cell carcinoma of the lung. The patient refused epidural catheter placement and underwent a left T5-6 thoracotomy under general anesthesia. During surgery, she was hemodynamically stable and good oxygen saturation was maintained. Several hours following surgery the patient complained of loss of sensation in her legs. Neurological examination disclosed a complete motor and sensory block at the T5-6 level. Magnetic resonance imaging (MRI) revealed spinal cord ischemia. The patient received iv steroid treatment, but remained paraplegic. Five months following the surgery there was only partial improvement in her motor symptoms. A follow-up MRI study was consistent with a diagnosis of spinal cord ischemia. In this case of paraplegia following thoracic surgery for lung resection, epidural anesthesia/analgesia was not used. The MRI demonstrated evidence of spinal cord ischemia, and no evidence of cord compression. This case highlights that etiologies other than epidural intervention, such as injury to the spinal segmental arteries during thoracotomy, should be considered as potential causes of cord ischemia and resultant paraplegia in this surgical population.

Over the last several years, there have been legal decisions and changes in medical directives concerning end-of-life decisions in Israel. The data were compared to evaluate the changes in the frequency and types of forgoing of life-sustaining treatment (FLST) in patients who were admitted to the ICU during period I (November 1994 to July 1995) and period II (January 1998 to January 1999). During period I, there were 385 ICU admissions, and during period II there were 627 ICU admissions. In period I, FLST or death occurred in 13.5% of patients, and in 12% in period II. There was no significant difference in cardiopulmonary resuscitation (9% vs 13%, respectively), withholding therapy (90% vs 91%, respectively), or withdrawing therapy (0% vs 0%, respectively) between the two study periods. There was no significant change in the frequency or types of FLST in an Israeli ICU between 1994 and 1998, despite passage of a new Patients’ Rights Law and the issuing of a Ministry of Health directive on the treatment of the terminally ill, both of which occurred in 1996, and recent district court decisions favoring the termination of life-sustaining therapies.

To assess clinical signs and management of primary blast lung injury (BLI) from explosions in an enclosed space and to propose a BLI severity scoring system. Retrospective analysis. Fifteen patients with primary BLI resulting from explosions on two civilian buses in 1996. Ten patients were extremely hypoxemic on admission (Pao2 < 65 mm Hg with oxygen supplementation). Four patients remained severely hypoxemic (Pao2/fraction of inspired oxygen (Fio2) ratio of < 60 mm Hg) after mechanical ventilation was established and pneumothoraces were drained. Initial chest radiographs revealed bilateral lung opacities of various sizes in 12 patients (80%). Seven patients (47%) had bilateral pneumothoraces and two patients had a unilateral pneumothorax. Five (33%) had clinically significant bronchopleural fistulae. After clinical and laboratory data were collected, a BLI severity score was defined based on hypoxemia (Pao2/Fio2ratio), chest radiographic abnormalities, and barotrauma. Severe BLI was defined as a Pao2/Fio2 ratio of< 60 mm Hg, bilateral lung infiltrates, and bronchopleural fistula; moderate BLI as a Pao2/Fio2 ratio of 60 to 200 mm Hg and diffuse (bilateral/unilateral) lung infiltrates with or without pneumothorax; and mild BLI as a Pao2/Fio2 ratio of> 200, localized lung infiltrates, and no pneumothorax. Five patients developed ARDS with Murray scores > 2.5. Respiratory management included positive pressure ventilation in the majority of the patients and unconventional methods (ie, high-frequency jet ventilation, independent lung ventilation, nitric oxide, and extracorporeal membrane oxygenation) in patients with severe BLI. Of the four patients who had severe BLI, three died. All six patients with moderate BLI survived, and four of five with mild BLI survived (one with head injury died). BLI can cause severe hypoxemia, which can be improved significantly with aggressive treatment. The lung damage may be accurately estimated in the early hours after injury. The BLI severity score may be helpful in determining patient management and prediction of final outcome.