תוצאת חיפוש

Propofol Anesthesia for Craniotomy in Patients who are Awake

Ron Ben Abraham, Noah Lieberman, Zvi Ram, Sylvia Klempner, Azriel Perel

Depts. of Anesthesia and Intensive Care and of Neurosurgery, Chaim Sheba Medical Center, Tel Hashomer and Sackler School of Medicine, Tel Aviv University

During craniotomy, the patient's cooperation is needed during procedures in which continuous neurological examination and mapping of crucial regions close to the area to be resected area are required. We report our experience in 9 patients who underwent such procedures under intravenous propofol as the main sedating agent. This short-acting hypnotic was administered prior to and during the painful stages of the procedure. Patients were fully asleep when the skull was opened and the dural flap raised or excised. During the rest of the operation patients were lightly sedated but remained responsive and cooperative. This enabled precise intra-operative mapping of the brain and surgery-related neurological deficits were avoided. Respiratory depression or hemodynamic compromise were not encountered. All patients were comfortable during the operation and there were no additional neurological deficits after operation. We believe that propofol should be the main sedating agent used for these procedures.

First Year's Experience of the Post, Operative Cardiac Care Unit, Schneider Children's Medical Center

O. Dagan, E. Birk, J. Katz, B. Vidne

Cardiothoracic Pediatric Service, Schneider Children's Medical Center, Petah Tikva

In the past 10 years there has been a growing preference for early, complete correction of congenital heart disease. The first year of operation of this cardiac unit is described. 216 operations were performed: 15% in the neonatal age group and 35% in the newborn to l-year-old groups; 2% were palliative procedures. Mortality was 4.9%. Average stay in the ICU was 3.2  days, with a median of 2.25. Average length of ventilation was 35 hours, with a median of 17.5. Complications were: diaphragm paralysis in 13 (6%), 2/3 of which were recurrent operations; in 2 patients (0.9%) we had to plicate the diaphragm. There was severe neurological damage in 2, which deteriorated to brain death in 1. There was peripheral, reversible neurological damage in 4 (1.8%), and acute renal failure in 3%, with half of them requiring dialysis. 75% of these children died and there was superficial infection in 4.1%, deep wound infection in 1.3%, bacteremia in 4.1%, superior vena cava syndrome in 3 (1.3%) and chylothorax in 2 of them (0.9%). 1 patient (0.45%) required a ventricle-peritoneal shunt after acute viral meningitis. We are encouraged by our results to offer early complete correction to all children with congenital heart disease.

Verapamil-Associated Liver Injury

Majed Odeh, Arie Oliven

Medical Dept. B, Bnai-Zion Medical Center and Faculty of Medicine, The Technion, Haifa

Hepatotoxicity due to verapamil is very rare and to the best of our knowledge only 10 cases have been reported. A 54-year-old woman developed cholestatic liver injury and pruritus following treatment with sustained-release verapamil (240 mg/day) for arterial hypertension. The pruritus and all hepatic biochemical abnormalities completely resolved after withdrawal of the drug. Similar to previously reported cases, the pathogenic mechanism of verapamil-associated liver injury in our patient was, most probably, idiosyncratic. These cases emphasize the need for awareness of the possibility that verapamil may occasionally induce liver injury, sometimes severe and potentially fatal.

Local Treatment of Purulent Chronic Otitis Media with Ciprofloxacin

Ludwig Podoshin, Alexander Brodzki, Milo Fradis, Jacob Ben-David, Josef Larboni, Isaac Srugo

Dept. of Otolaryngology, Head and Neck Surgery, Microbiology Unit and Dept. of Pharmacology, Bnai-Zion Medical Center, and Bruce Rappaport Faculty of Medicine, The Technion, Haifa

We evaluated the efficacy of ciprofloxacin eardrops compared to tobramycin and to a placebo in the treatment of chronic suppurative otitis media. 60 ears were randomly assigned to treatment for 3 weeks with ciprofloxacin, tobramycin or placebo eardrops. The organism most commonly isolated from the ear discharge was Pseudomonas aeruginosa. The clinical responses were 78.9% and 72.2%, respectively, in the ciprofloxacin and tobramycin groups, while it was only 41.2% in the placebo group. Treatment with ciprofloxacin eardrops seemed to be at least as efficient as treatment with tobramycin. Considering the lack of ototoxicity of ciprofloxacin, this treatment may be best for chronic otitis media.

Fungus-Ball in a Preterm Infant Successfully Treated with Fluconazole

Mirit Hershman-Sarafov, Orora Tubi, Isaac Srugo, David Bader

Neonatal and Radiology Depts., and Microbiology Laboratory, Bnai-Zion Medical Center and Bruce Rappaport Faculty of Medicine, The Technion, Haifa

Very-low-birth-weight premature infants are at high risk for invasive candidiasis. The most commonly involved organ is the kidney. Renal candidiasis may present as fungus-ball obstructive uropathy. We describe unilateral renal obstruction secondary to fungus-ball in a premature infant. Noninvasive, systemic antibiotic treatment, including amphotericin B and fluconazole, resulted in disappearance of the finding.

Conservative Approach in Children with Central Line Infection 

Zvi Steiner, Yafim Kandelis, George Mogilner, Dina Atias, Isaac Srugo

Dept. of Pediatric Surgery, and Hematology and Clinical Microbiology Units, Bnei-Zion Medical Center, and Bruce Rappaport Faculty of Medicine, The Technion, Haifa

In 1994-1995, central venous lines were placed in 47 children. All except 1 were of the Broviac type, with subcutaneous tunneling via the internal or external jugular vein. Ages were between 7 days and 16 years. Indications for central venous cannulation were chemotherapy (35 cases), TPN (5), prolonged parenteral antibiotics (4), and repeated blood transfusions (3). The catheter was the source of infection in 13 children (28%), 11 of whom were immunocompromised. The commonly identified bacteria were Staphylococcus aureus (4 cases), Pseudomonas aeruginosa (4), coagulase-negative Staphylococcus (2), and various gram-negative rods (3). All cases were treated with antibiotics through the catheter. The most commonly used were oxacillin (4), ceftazidime (4), and amikacin (4). In 10, treatment succeeded without having to remove the line. In 2 others, tunnel infection developed and the catheter had to be removed. 1 child forcefully removed his catheter before treatment could be started. There were no further complications in the group treated conservatively, except for a case of superior vena cava thrombosis in a girl with recurrent infection of the tunnel. In 7 out of 13 treatment was continued and completed at home. This saved 65 days of hospitalization out of 210. We conclude that the conservative approach to treatment is feasible in most cases of infection when the source is the central venous catheter itself. However, when the tunnel is infected, conservative treatment may be ineffective. Treatment can be carried out in the home, with economy in cost and in use of hospital beds, and is preferred by patients and their parents.

Percutaneous Ablation of Malignant Kidney Tumors in Rabbits by Low Frequency Radio Energy

Boaz Moskovitz, Ofer Nativ, Edmond Sabo, Yousef Barbara, Daniel Mordohovich, Yoseph Kaftori, Arie Shalhav, Benad Goldwasser

Bnai-Zion Medical Center and Bruce Rappaport Faculty of Medicine, The Technion, Haifa

Radio-frequency (RF) current has been used successfully to ablate normal human tissue. To investigate further the clinical application of this modality in tumors, we studied the potential of using RF percutaneously to destroy experimental kidney tumors. 35 outbred albino rabbits underwent direct-implantation of renal VX2 tumor during open surgery. After 21 days, ultrasonography was performed to show tumor presence and size. A shielded RF needle was designed to be inserted percutaneously through an introduction needle. An electrical insulation shield covering the RF needle was retractable, controlling the length of exposure of the RF needle inside the tissue. 22 days after tumor implantation, RF was applied via this special needle using a ZoMed International RF generator. In one group of rabbits the procedure was performed under direct vision during open surgery, while in another group treatment was percutaneous, the needle guided by palpation of the tumor. Rabbits were killed 3 days later and revealed 4-25 mm intra-tumoral RF-induced lesions. A direct relation was found between lesion size and the power and duration of RF applied (at 7.5 W, R=0.48, and P=0.32). Based on our preliminary results we can conclude that RF may have clinical applications in the near future for percutaneous local tumor control in parenchymal organs.

Incidence, Antimicrobial Resistance and Mortality in Bloodstream Infections in the Critically Ill

Lavi Oud, Shelly Krimerman, Isaac Srugo

General Intensive Care Unit and Clinical Microbiology Dept., Bnai-Zion Medical Center, Haifa

Bloodstream infections (BSI) are 7-fold more common in patients admitted to the intensive care unit (ICU) rather than to other hospital wards. The epidemiology of BSI in critically ill patients in Israel has not been systematically addressed. We examined the annual trends in BSI in patients in a general ICU of evolving patterns of antimicrobial resistance and associated mortality rates for the years 1994-1996. The presence of the systemic inflammatory response syndrome (SIRS) when the first positive blood cultures are taken was a prerequisite for its definition as clinically significant. The unit site, staff, practice guidelines, and type of patient were unchanged during the study period. Blood cultures were positive in 220.7-332.0 patients per 1000 ICU admissions, 18-22-fold more common than in regular ward patients. SIRS was a universal finding in these ICU patients. There was multi-drug resistance for the majority of species cultured, reaching 100% in some cases. Crude hospital mortality of ICU patients, with and without positive blood cultures, was 31-54% and 5-14%, respectively. The introduction of a new blood culture system (Bactec 9240) in 1996 was associated with a 61% increase in the rate of patients with positive blood cultures, accounted for mostly by increased isolation of coagulase-negative staphylococci. However the mortality rate for the latter decreased by 59%, suggesting the possibility of a selective increase in detection of contaminated cultures. Although highly prevalent in the study population and generally defining a patient group with high mortality risk, the specificity of SIRS-associated positive blood cultures may be species and culture-system dependent. These findings re-emphasize the need for both improved control measures for the epidemic proportions of BSI and multi-drug antimicresistance, as well as more specific indicators of the clinicaof positive blood cultures in critically ill patients.

Gentamycin Distribution Volume in a Mechanically Ventilated Patient

H. Seligmann, S. Nicola, S.H. Krimerman

Clinical Pharmacology and Intensive Care Units, Bnai-Zion Medical Center and Bruce Rappaport Faculty of Medicine, The Technion, Haifa

Mechanical ventilation (MV) of more than 32 hours may alter the gentamycin pharmacokinetic profile by increasing its volume of distribution (VD). As a result, the standard garamycin dosage regime has to be adjusted in order to obtain an adequate peak serum concentration, which is well correlated with the efficacy of garamycin therapy. Garamycin is a water- soluble drug with negligible binding to plasma albumin, so its VD approximates the volume of extra-cellular fluid, which may be expanded by MV. MV-related fluid retention is mediated via various homeostatic compensatory systems. They are activated to combat the decrease in cardiac output and central blood volume caused by MV, due to the increase in airway and intrathoracic pressure. These phenomena are more prominent during prolonged ventilation, PEEP or C-PAP ventilation, and in previously hypovolemic patients. Patients requiring MV for more than 32 hours had an average garamycin VD of 0.36 L/Kg compared with the mean VD of 0.25 L/Kg in normal adults. In the patient presented, a similar change in garamycin VD was seen, while conventional doses given during MV failed to reach suitable clinical peak levels.

Continuous Quality Improvement in Anesthesia

Luis Gaitini, Sonia Vaida, Shahar Madgar

Depts. of Anesthesia and of Urology, Bnai-Zion Medical Center, Haifa

Slow continuous quality improvement (SCQI) in anesthesia is a process that allows identification of problems and their causes. Implementing measures to correct them and continuous monitoring to ensure that the problems have been eliminated are necessary. The basic assumption of CQI is that the employees of an organization are competent and working to the best of their abilities. If problems occur they are the consequences of inadequacies in the process rather that in the individual. The CQI program is a dynamic but gradual system that invokes a slower rate of response in comparison with other quality methods, like quality assurance. Spectacular results following a system change are not to be expected an the ideal is slow and continuous improvement.

A SCQI program was adapted by our department in May 1994, according to the recommendations of the American Society of Anesthesiologists. Problem identification was based on 65 clinical indicators, reflecting negative events related to anesthesia. Data were collected using a specially designed computer database. 4 events were identified as crossing previously established thresholds (hypertension, hypotension, hypoxia and inadequate nerve block). Statistical process control was used to establish stability of the system and whether negative events were influenced only by the common causes. The causes responsible for these negative events were identified using specific SCQI tools, such as control-charts, cause-effect diagrams and Pareto diagrams. Hypertension and inadequate nerve block were successfully managed. The implementation of corrective measures for the other events that cross the threshold is still in evolution. This program requires considerable dedication on the part of the staff, and it is hoped that it will improve our clinical performance.

Evolving Role of Radiation Therapy in Nonmalignant Disorders

Rami Ben-Yosef

Bone Marrow Transplant Dept., Hadassah Hospital, Jerusalem

Various nonmalignant disorders have traditionally been treated with radiation therapy. It has almost completely been discontinued due to reports of secondary malignancy. During the past 15 years there has been an evolving role for radiation therapy in various nonmalignant disorders such as meningioma, A-V malformation, prevention of vascular restenosis and heterotopic bone formation. Appropriate follow-up of such patients for diagnosis of secondary malignancy is recommended. Radiation therapy should be carefully considered in diseases not successfully treated with conventional means.

Compulsory, Ambulatory Psychiatric Treatment

R. Durst, A. Teitelbaum, Y. Bar-El, M. Shlafman, Y. Ginath

Arie Jaros Jerusalem Mental Health Center and Talbieh Mental Health Center (Affiliated with the Hebrew University-Hadassah Medical School, Jerusalem) and Israel Ministry of Health, Jerusalem District

The Treatment of Mentally Sick Persons Law of 1955, was repealed and replaced by the Law of 1991. Under the latter, the Order for Compulsory Ambulatory Treatment (OCAT) was addressed for the first time (Section 11, a-d). According to this law, the district psychiatrist instead of issuing a hospitalization order, may issue an OCAT, under which the required treatment is given within the scope of a clinic which he designates, for up to 6 months and under conditions which he specifies. This is done on the basis of psychiatric examination, or an application in writing from the director of a hospital or clinic, when continued ambulatory treatment is needed after discharge from hospital or instead of compulsory hospitalization. The district psychiatrist may extend the period of treatment for further periods, none of which is to exceed 6 months. Compulsory ambulatory treatment is to enable patients to benefit from the positive aspects of living freely in the community, while receiving prompt treatment under compulsory conditions. The concept offers a partial solution, achieving a balance between civil liberties and clinical needs, between over-confinement and under-treatment which might be dangerous or neglectful. The clinical impression has been that the OCAT has not fulfilled expectations. The purpose of this study was to examine the topic in a systematic way in Jerusalem and the soutern districts for the 4 years since inception of the law. In 44.4% of cases OCAT was proven to be effective, while in 33.1% it was found to be ineffective and did not prevent compulsory hospitalization, one of its main goals. It was partially effective in the rest of the cases. It is recommended that suitable means for the enforcement of the law be allocated and that the subject of forceful hospitalization and OCAT be made a mandatory subject in the residency program of psychiatrists.

Radiotherapy of Localized Prostatic Carcinoma

Eliahu Gez, Yael Netzer-Horowitz, Einat Waiman, Raphael Rubinov, Yoram Cohen, Abraham Kuten

Northern Israel Oncology Center and Oncology Dept., Rambam Medical Center and Lin Medical Center, Haifa; and Soroka Medical Center, Beer Sheba

112 patients with localized prostate cancer, clinical stage A2-C, were treated by definitive radiotherapy between 1982-1988. Radiation volume encompassed the prostate, seminal vesicles and pelvic lymph nodes. The 10-year actuarial survival figures were: overall 51%; stage A2 87%; stage B 50%; stage C 36%; well differential tumors 67%; moderately differentiated 50%; poorly differentiated 32%; patients with local tumor control 55%; and patients with minimal local control 36%. It is concluded that external beam irradiation is effective in localized prostatic cancer. Stage and grade are prognosticators of survival.

Bromocriptine for Refractory Rheumatoid Arthritis

Reuven Mader

Rheumatic Disease Unit, HaEmek Medical Center, Afula

In recent years prolactin (PRL) has emerged as an important immunomodulator in various autoimmune disorders. Bromocriptine (BRC) is a dopamine agonist that suppresses secretion of PRL. Good clinical response to BRC has been reported in patients with psoriatic arthritis, Reiter's syndrome, and systemic lupus erythematosus. 5 mg of BRC at bedtime were given to 5 patients (aged 35-50) with refractory rheumatic arthritis (RA) who had failed to respond to previous treatment with at least 2 disease-modifying antirheumatic drugs. Patients were assessed at 4-6 week intervals for 6 months. 3 showed more than 25% improvement in the number of tender and swollen joints at 12 weeks of treatment. However, in only 2 of them was improvement maintained till the end of the 6 months. There were no changes in other measures of disease activity. 1 patient dropped out of the study due to acute exacerbation of her disease 4 weeks after initiation of BRC and required intra-articular injections of corticosteroid. The remaining patient did not show any significant clinical changes. No correlation was found between serum PRL levels and disease activity over time. It is suggested that some patients with refractory RA might improve with BRC. Its use in larger doses in larger groups of patients may help elucidate its role in the treatment of RA.

Incomplete Penile Amputation: Diagnostic and Therapeutic Challenge

D. Leibovici, B. Yaffe, A. Zisman

Urology Dept., Assaf Harofeh Medical Center and Microsurgery Dept., Chaim Sheba Medical Center, Tel Hashomer

Traumatic penile amputation is a severe injury associated with a potential for multidisciplinary dysfunction. Since such injuries are rare, diagnostic and therapeutic experience is minimal. While complete penile amputation is a straight-forward diagnosis, incomplete amputations are not as evident and diagnosis may be delayed. The therapeutic endpoint includes restoration of an acceptable appearance of the phallus and a urethral meatus that allows normal voiding. Other objectives include re-establishment of sexual potency and fertility. As in other amputations, the treatment of choice is meticulous microsurgical replantation, including re-anastomosis of dorsal and cavernosal arteries, the deep dorsal vein, the urethra and nerves, as well as suturing the tunica albuginea. While appropriate cosmetic results and normal voiding can be achieved in most cases, potency is less frequently achieved due to neurological deficit leading to impaired erection and loss of sensation. Penile amputation is thus a complex therapeutic challenge, as meticulous anatomic reconstruction of blood vessels and nerves is essential for restoration of function. Since incomplete penile amputation may be overlooked when other more obvious injuries draw attention, this injury should be suspected in all cases of penetrating injury of the male genitalia. We present a 17-year-old man who sustained an incomplete penile amputation in a traffic accident.