Crowson MG, Berger M, McCarthy GC, Powers DB. Orbitocerebral Impalement: Case Discussion and Management Algorithm. Craniomaxillofacial Trauma and Reconstruction. 2016 August 29. (eFirst).
Orbitocerebral impalement by inanimate objects is a relatively uncommon event. If orbitocerebral impalement is suspected, management entails prompt referral to a trauma facility with neurosurgical, neuroanesthesiological, craniomaxillofacial, and ophthalmological expertise. The aim of this report is to describe the unique mechanism and perioperative considerations of a remarkable, deep orbitocerebral impalement from a walker brake lever through the orbital roof after a fall from standing. We discuss clinical vignette, evaluation, anesthetic approach, and considerations and review the literature on the epidemiology, pathophysiology, surgical and anesthetic management, and prognosis of this traumatic mechanism. We also offer a management algorithm that aims to streamline management.
Yalamuri S, Maxwell C. Preoperative Cold Agglutinin Testing: Consider an Algorithm. J Cardiothorac Vasc Anesth. 2016 Sep 28. pii: S1053-0770(16)30430-X. [Epub ahead of print]
Zhang L, Liu X, Sheng H, Liu S, Li Y, Zhao JQ, Warner DS, Paschen W, Yang W. Neuron-Specific SUMO Knockdown Suppresses Global Gene Expression Response and Worsens Functional Outcome After Transient Forebrain Ischemia in Mice. Neuroscience. 2016 Dec 2. pii: S0306-4522(16)30657-1. [Epub ahead of print]
Small ubiquitin-like modifier (SUMO) conjugation (SUMOylation) plays key roles in neurologic function in health and disease. Neuronal SUMOylation is essential for emotionality and cognition, and this pathway is dramatically activated in post-ischemic neurons, a neuroprotective response to ischemia. It is also known from cell culture studies that SUMOylation modulates gene expression. However, it remains unknown how SUMOylation regulates neuronal gene expression in vivo, in the physiologic state and after ischemia, and modulates post-ischemic recovery of neurologic function. To address these important questions, we used a SUMO1-3 knockdown (SUMO-KD) mouse in which a Thy-1 promoter drives expression of 3 distinct microRNAs against SUMO1-3 to silence SUMO expression specifically in neurons. Wild-type and SUMO-KD mice were subjected to transient forebrain ischemia. Microarray analysis was performed in hippocampal CA1 samples, and neurologic function was evaluated. SUMOylation had opposite effects on neuronal gene expression before and after ischemia. In the physiological state, most genes regulated by SUMOylation were up-regulated in SUMO-KD compared to wild-type mice. Brain ischemia/reperfusion significantly modulated the expression levels of more than 400 genes in wild-type mice, with a majority of those genes upregulated. The extent of this post-ischemic transcriptome change was suppressed in SUMO-KD mice. Moreover, SUMO-KD mice exhibited significantly worse functional outcome. This suggests that suppression of global gene expression response in post-ischemic brain due to SUMO knockdown has a negative effect on post-ischemic neurologic function. Together, our data provide a basis for future studies to mechanistically link SUMOylation to neurologic function in health and disease.
Joshi G, Gandhi K, Shah N, Gadsden J, Corman SL. Peripheral Nerve Blocks in the Management of Postoperative Pain: Challenges and Opportunities. J Clin Anesth. 2016 Dec;35:524-529. Epub 2016 Oct 20.
Peripheral nerve blocks (PNBs) are increasingly used as a component of multimodal analgesia and may be administered as a single injection (sPNB) or continuous infusion via a perineural catheter (cPNB). We undertook a qualitative review focusing on sPNB and cPNB with regard to benefits, risks, and opportunities for optimizing patient care. Meta-analyses of randomized controlled trials have shown superior pain control and reductions in opioid consumption in patients receiving PNB compared with those receiving intravenous opioids in a variety of upper and lower extremity surgical procedures. cPNB has also been associated with a reduction in time to discharge readiness compared with sPNB. Risks of PNB, regardless of technique or block location, include vascular puncture and bleeding, nerve damage, and local anesthetic systemic toxicity. Site-specific complications include quadriceps weakness in patients receiving femoral nerve block, and pleural puncture or neuraxial blockade in patients receiving interscalene block. The major limitation of sPNB is the short (12-24 hours) duration of action. cPNB may be complicated by catheter obstruction, migration, and leakage of local anesthetic as well as accidental removal of catheters. Potential infectious complications of catheters, although rare, include local inflammation and infection. Other considerations for ambulatory cPNB include appropriate patient selection, education, and need for 24/7 availability of a health care provider to address any complications. The ideal PNB technique would have a duration of action that is sufficiently long to address the most intense period of postsurgical pain; should be associated with minimal risk of infection, neurologic complications, bleeding, and local anesthetic systemic toxicity; and should be easy to perform, convenient for patients, and easy to manage in the postoperative period.