Hyperosmolar, increased-anion-gap metabolic acidosis and hyperglycemia after etomidate infusion.

Hyperosmolar increased-anion-gap metabolic acidosis without hyperglycemia has been reported after infusions of etomidate and other medications containing propylene glycol. We report a case of this biochemical abnormality with severe hyperglycemia. Cessation of the etomidate infusion along with other supportive measures resulted in prompt resolution of the metabolic acidosis and hyperglycemia.

Qualitative thrombelastographic detection of tissue factor in human plasma.

Background: Tissue factor (TF) is the principal in vivo initiator of coagulation, with normal circulating TF concentrations reported to be approximately 23-158 pg/mL. However, patients with atherosclerosis or cancer have been reported to have TF concentrations ranging between 800 and 9000 pg/mL. Of interest, thrombelastographic (TEG)-based measures of clot initiation and propagation have demonstrated hypercoagulability in such patients at risk for thromboembolic events.

Recurrent laryngeal nerve palsy after anterior cervical spine surgery: the impact of endotracheal tube cuff deflation, reinflation, and pressure adjustment.

Background: Vocal fold immobility (paresis or paralysis) from recurrent laryngeal nerve injury remains an important cause of morbidity after anterior cervical spine surgery. A maneuver involving endotracheal tube (ETT) cuff manipulation has been proposed to reduce its incidence. This study is a randomized, prospective, double-blind investigation to test the hypothesis that ETT cuff manipulation reduces the incidence of postoperative vocal fold immobility after anterior cervical spine surgery.

The impact of tissue factor pathway inhibitor on coagulation kinetics determined by thrombelastography.

Background: Tissue factor pathway inhibitor (TFPI) is a 40-kDa, endogenous protein that inhibits tissue factor (TF)-initiated coagulation by bonding with activated factor X (FXa). The TFPI/FXa complex then subsequently binds with TF/activated factor VII (FVIIa) complex, ultimately inhibiting thrombin generation. Heparin administration causes endothelial release of TFPI concentrations up to sixfold normal values.

Plasma ropivacaine levels during awake intracranial surgery.

Plasma ropivacaine levels produced by routine scalp infiltration for field block were assayed in eight patients undergoing awake intracranial surgery. Levels peaked within approximately 13 minutes, indicating rapid systemic absorption of ropivacaine. Potentially toxic plasma drug levels were achieved in three of eight patients, although no untoward effects attributable to elevated levels of ropivacaine were observed.

Reevaluation of surgery for the treatment of brain metastases: review of 208 patients with single or multiple brain metastases treated at one institution with modern neurosurgical techniques.

Objective: Patients with brain metastases were analyzed retrospectively to assess the risks and benefits of surgery with modern neurosurgical techniques, including image guidance coupled as indicated with corticography.

Methods: We retrospectively analyzed charts of patients treated surgically for brain metastases. We identified patients with single or multiple brain metastases who underwent craniotomies to reverse associated neurological symptoms or establish a diagnosis.

An unusual case of emergence delirium.

We present a case of postoperative delirium following endoscopic sinus surgery. We postulate a mechanism for this rare event.

Use of cuffed oropharyngeal airway (COPA) for awake intracranial surgery.

A comprehensive anesthetic plan for managing patients undergoing "awake: intracranial surgery (AICS) must include a means of rescuing the patient if the airway becomes obstructed. Since access to the patient's airway is limited, mask ventilation can be challenging and laryngoscopy and tracheal intubation, impossible. The need exists for an alternative airway device that is easy to insert, would allow controlled ventilation, and would facilitate a smooth emergence with minimal coughing.