The amount of compensatory sweating depends on the patient, the damage that the white rami communicans incurs, and the amount of cell body reorganization in the spinal cord after surgery.
Other potential complications include inadequate resection of the ganglia, gustatory sweating, pneumothorax, cardiac dysfunction, post-operative pain, and finally Horner’s syndrome secondary to resection of the stellate ganglion.
www.ubcmj.com/pdf/ubcmj_2_1_2010_24-29.pdf

After severing the cervical sympathetic trunk, the cells of the cervical sympathetic ganglion undergo transneuronic degeneration
After severing the sympathetic trunk, the cells of its origin undergo complete disintegration within a year.
http://onlinelibrary.wiley.com/doi/10.1111/j.1439-0442.1967.tb00255.x/abstract

Monday, February 16, 2009

Safety and Ethics in Healthcare

"...professionals may adopt unreasonable practices. Practices may develop in professions, particularly as to disclosure, not because they serve the interests of the clients, but because they protect the interests or convenience of members of the profession. The court has an obligation to scrutinize professional practices to ensure that they accord with the standard of reasonableness imposed by the law."
Incresingly, the question is not whether the defendant's conduct conforms with the practices of the profession, but whether it conforms with standards of reasonableness. (p. 150)

The right of patients self-determination is well entrenched both in law and in ethical codes. Respect for patient autonomy now occupies centre stage in medical ethics. In considerin patient autonomy one needs to think about truth telling, confidentiality, privacy, disclosure of information and consent. Each is important and all have important implications for healthcare professionals. (p. 167)

Safety and Ethics in Healthcare: A Guide to Getting it Right
By Bill Runciman, Alan Merry
Published by Ashgate Publishing, Ltd., 2007
ISBN 0754644375, 9780754644378


Some secondary effects of sympathectomy; with particular reference to disturbance of sexual function

N Engl J Med. 1951 Jul 26;245(4):121-30.
WHITELAW GP, SMITHWICK RH.

PMID: 14853048 [PubMed - indexed for MEDLINE]

causes of autonomic dysfunction - sympathectomy

Patients with progressive autonomic dysfunction (including diabetes) have little or no increase in plasma noradrenaline and this correlates with their orthostatic intolerance (Bannister, Sever and Gross, 1977). In patients with pure autonomic failure, basal levels of noradrenaline are lower than in normal subjects (Polinsky, 1988). Similar low values are observed in patients with sympathectomy and in patients with tetraplegia. (p.51)

The finger wrinkling response is abolished by upper thoracic sympathectomy. The test is also abnormal in some patients with diabetic autonomic dysfunction, the Guillan-Barre syndrome and other peripheral sympathetic dysfunction in limbs. (p.46)

Other causes of autonomic dysfunction without neurological signs include medications, acute autonomic failure, endocrine disease, surgical sympathectomy . (p.100)

Anhidrosis is the usual effect of destruction of sympathetic supply to the face. However about 35% of patients with sympathetic devervation of the face, acessory fibres (reaching the face through the trigeminal system) become hyperactive and hyperhidrosis occurs, occasionally causing the interesting phenomenon of alternating hyperhidrosis and Horner's Syndrome (Ottomo and Heimburger, 1980). (p.159)


Disorders of the Autonomic Nervous System
By David Robertson, Italo Biaggioni
Edition: illustrated
Published by Informa Health Care, 1995
ISBN 3718651467, 9783718651467

Hyperhidrosis is more than sympathetic overactivity

Our overall findings suggest that essential hyperhidrosis is a complex autonomic dysfunction rather than sympathetic overactivity, and parasympathetic system seems to be involved in pathogenesis of this disorder.

Annals of Noninvasive Electrocardiology


Volume 10 Issue 1, Pages 1 - 6

Published Online: 13 Jan 2005

Journal compilation © 2009 Wiley Periodicals, Inc.

interrupting sympathetic efferent fibers innervating the heart and baroreflex

The results suggest that cardiac sympathectomy induced by epidural anesthesia can suppress partially baroreceptor function by interrupting sympathetic efferent fibers innervating the heart during high levels of epidural anesthesia, but that lumbar sympathectomy during epidural anesthesia is unlikely to affect baroreceptor activity.
Baroreflex control of heart rate during cardiac sympathectomy by epidural anesthesia in lightly anesthetized humans.

Dohi S, Tsuchida H, Mayumi T
Anesth Analg 1983; 62:815-20.

Baroreflex sensitivity, measured as cardiac acceleration in response to nitroglycerin, was significantly lower (p < 0.01) in groups 1 and 2 (1.8 and 1.5 ms.mmHg-1 respectively) compared with group 3 (3.5 ms.mmHg-1) with no differences between the two bupivacaine concentrations. The results suggest that baroreflex-mediated response to decreases in arterial pressure is dependent on the integrity of the sympathetic nervous system.

Baroreflex control of heart rate during high thoracic epidural anaesthesia. A randomised clinical trial on anaesthetised humans.
Goertz A, Heinrich H, Seeling W
Anaesthesia 1992; 47:984-7.

How sympathetic tone maintains or alters arterial pressure

After chronic sympathectomy or sinoaortic denervation (SAD), arterial pressure (AP) becomes extremely unstable, especially because of movement-related depressor episodes. The simultaneous measurement of AP and regional blood flows in sympathectomized and SAD rats indicates that these depressor episodes are accompanied by strong regional vasodilations, possibly involving an autoregulatory component.

It is concluded that both stability and normal variability of AP critically depend on the baroreflex control of the sympathetic vascular tone.
Fundam Clin Pharmacol. 1995;9(4):343-9. PMID: 8566933 [PubMed - indexed for MEDLINE]

Endoscopic thoracic sympathectomy suppressed the baroreflex control of heart rate during pressor and depressor tests in patients with palmar or axillary hyperhidrosis.
We conclude that baroreflex responses are suppressed in patients who receive ETS.

Anesth Analg. 2004 Jan;98(1):37-9, table of contents.Click here to read

PMID: 14693579 [PubMed - indexed for MEDLINE]

Autonomic neuropathy simulating the effects of sympathectomy

Autonomic neuropathy simulating the effects of sympathectomy as a complication of diabetes mellitus. Diabetes 1955;4:92-97.
Odel HM, Roth GM, Keating FR,

Dysautonomias: Clinical Disorders of the Autonomic Nervous System

The term dysautonomia refers to a change in autonomic nervous system function that adversely affects health. The changes range from transient, occasional episodes of neurally mediated hypotension to progressive neurodegenerative diseases; from disorders in which altered autonomic function plays a primary pathophysiologic role to disorders in which it worsens an independent pathologic state; and from mechanistically straightforward to mysterious and controversial entities. In chronic autonomic failure (pure autonomic failure, multiple system atrophy, or autonomic failure in Parkinson disease), orthostatic hypotension reflects sympathetic neurocirculatory failure from sympathetic denervation or deranged reflexive regulation of sympathetic outflows. Chronic orthostatic intolerance associated with postural tachycardia can arise from cardiac sympathetic activation after "patchy" autonomic impairment or blood volume depletion or, as highlighted in this discussion, from a primary abnormality that augments delivery of the sympathetic neurotransmitter norepinephrine to its receptors in the heart. Increased sympathetic nerve traffic to the heart and kidneys seems to occur as essential hypertension develops. Acute panic can evoke coronary spasm that is associated with sympathoneural and adrenomedullary excitation. In congestive heart failure, compensatory cardiac sympathetic activation may chronically worsen myocardial function, which rationalizes treatment with ß-adrenoceptor blockers. A high frequency of positive results on tilt-table testing has confirmed an association between the chronic fatigue syndrome and orthostatic intolerance; however, treatment with the salt-retaining steroid fludrocortisone, which is usually beneficial in primary chronic autonomic failure, does not seem to be beneficial in the chronic fatigue syndrome. Dysautonomias are an important subject in clinical neurocardiology.
right arrow David S. Goldstein, MD, PhDModerator:; David Robertson, MDDiscussants:; Murray Esler, MD; Stephen E. Straus, MD; and Graeme Eisenhofer, PhD

5 November 2002 | Volume 137 Issue 9 | Pages 753-763

NIH CONFERENCE

PMID: 12416949 [PubMed - indexed for MEDLINE]

Exaggerated responses to drugs

Exaggerated responses to drugs following nervous system lesions were described in the medical literature more than a century ago. Although the phenomenon of supersensitivity is still not completely understood, studies in experimental animals have clarified the distinction between denervation and decentralization (for review see Trendelenberg, 1963). These characteristic pharmacologic abnormalities form the basis for distinguishing pre-, and post-ganglionic noradrenergic involvement.
Chronic postgangliionic denervation increases the pressor response to NA, while the effects of indirect symphatomimetics are reduced. Decentralization causes more modest changes in the blood pressure response and is not associated with loss of neuronal NA stores; the increase in pressor sensitivity is non-specific.

Disorders of the Autonomic Nervous System
By David Robertson, Italo Biaggioni
Published by Informa Health Care, 1995
ISBN 3718651467, 9783718651467

Peripheral SNS and Cerebral Blood Flow

Immediately following experimentation the cerebral vessels were examined
for the presence of noradrenergic fibers. The results of the study demonstrate that: (1) superior
cervical ganglionectomy produces a significant reduction in the noradrenergic innervation of ip-
silateral extraparenchymal arteries; (2) the peripheral sympathetic nervous system contributes
to overall cerebral vascular resistance primarily by affecting resistance in extraparenchymal
arteries; and (3) as a result, it determines the contribution of the extraparenchymal arteries tooverall cerebral blood flow autoregulation.
1975;6;284-292 Stroke

Regulation of peripheral inflammation

It is clear that the spinal adenosine effect requires intact somatic connectivity. Information on pain and inflammation in the periphery is transmitted to the nervous system, where increased spinal adenosine levels can suppress peripheral inflammation.
Experimental Neurology
Volume 184, Issue 1, November 2003, Pages 162-168


Thoracoscopy performed under sedation-assisted local anesthesia is associated with significant hypoventilation

Thoracoscopy performed under sedation-assisted local anesthesia is associated with significant hypoventilation. Combined measurement of Spo2 and Pcco2 during thoracoscopy is a novel approach in the monitoring of ventilation, enhancing patient safety, and might allow to guide the administration of sedation in a better way.

Mean baseline Pcco2 measurement was 39.1 ± 7.2 mm Hg (± SD) [range, 27.5 to 50.5 mm Hg], and peak measurement during the procedure was 52.3 ± 10.3 mm Hg (range, 37.2 to 77 mm Hg) [p < class="sc">co2 measurement from baseline were 13.0 mm Hg and 13.2 ± 5.3 mm Hg (range, 5.5 to 27.8 mm Hg), respectively. Mean fall in Spo2 during the procedure was 4.6 ± 3.2% (range, 1 to 14%).

(The Paratrend 7 monitoring system (PT7), which was used in our study, is a widely validated and accepted method of continuous intraarterial blood gas measurement with good accuracy and performance. Apart from our own results in patients undergoing thoracoscopic interventions with one-lung ventilation (2), this device has been validated in an experimental study (3). In the intensive care unit (4), and during cardiac surgery (5). Furthermore, this device was used by two other groups, and their results have also been published (6,7). Nevertheless, in our study, we provided ample data on the good agreement of PT7 data with laboratory blood gas analyses. In fact, whenever a laboratory blood gas analysis was performed, PT7 values were recorded simultaneously and used for bias/precision analysis. We found an overall limit of agreement for bias/precision of -3.4/15.9 mm Hg in the clinically most important range of PaO2 values <100> a PaO2 value of 65 mm Hg obtained by PT7 could be as low as 45.7 mm Hg or as high as 77.5 mm Hg. However, both values clearly indicate hypoxemia under an inspired oxygen fraction of 1.0 and, thus, represent a critical medical condition.)

Detection of Hypoventilation During Thoracoscopy*

Combined Cutaneous Carbon Dioxide Tension and Oximetry Monitoring With a New Digital Sensor

  1. Prashant N. Chhajed, MD, FCCP,
  2. Bruno Kaegi,
  3. Rajeevan Rajasekaran, and
  4. Michael Tamm, MD
CHEST February 2005 vol. 127 no. 2 585-588

Substantial changes in arterial blood gases during thoracoscopic surgery

Zaugg M, Lucchinetti E, Zalunardo M, et al. Substantial changes in arterial blood gases during thoracoscopic surgery can be missed by conventional intermittent laboratory blood gas analysis. Anesth Analg. 1998;87:647-653.

Substantial and clinically relevant changes in arterial blood gases are likely to occur during thoracoscopic surgery with one-lung ventilation (OLV). We hypothesized that they may be missed when using the conventional intermittent blood gas sampling practice. Therefore, during 30 thoracoscopic procedures with OLV, the sampling intervals between consecutive intermittent laboratory blood gas analyses (BGA) were evaluated with respect to changes of PaO2, PaCO2, and pHa ([H+]) using a continuous intraarterial blood gas monitoring system.
Extreme fluctuations of PaO2 (37-625 mm Hg), PaCO2 (27-56 mm Hg), and pHa (7.24-7.51) were observed by continuous blood gas monitoring. During 63% of all sampling intervals, PaO2 decreased >20% compared with the preceding BGA value, which remained undetected by intermittent analysis. In 10 patients with a continuously measured minimal PaO2 value < or =" 60"> overestimated this minimal PaO2 by > 47%. Correspondingly, PaCO2 increases of > 10% were observed in 35% of all sampling intervals, and [H+] increases of > 10% were observed in 24% of all sampling intervals. Because these blood gas changes were not reliably detected by using noninvasive monitoring and their magnitude is not predictable during OLV, intermittent BGA with short sampling intervals is warranted. In critical cases, continuous blood gas monitoring may be helpful.
http://www.anesthesia-analgesia.org/cgi/content/abstract/87/3/647

Arterial oxygen desaturation during only one of two similar thoracoscopic procedures on the same patient

PFITZNER J. (1) ; FOWLIE J. A. (1) ; KISHORE M. (1) ; MICHAEL A. S. (1) ; LANCE D. G. (1) ;


(1) Department of Anaesthesia and Thoracic Surgery Unit, The Queen Elizabeth Hospital, Woodville, South Australia, AUSTRALIE
Because acute hypoxia had developed during one-lung ventilation on the first occasion, serial blood gases were taken during the second. Also, whereas on the first occasion the non-ventilated lung had been left open to air when one-lung ventilation was initiated, on the second it was connected to an ambient pressure oxygen source with the object of theoretically enabling apnoeic oxygenation during lung collapse. It is argued that this fundamental difference in anaesthetic practice may have contributed to the improved oxygenation that was recorded during the second thoracoscopy.

Anaesthesia and intensive care ISSN 0310-057X CODEN AINCBS
2005, vol. 33, no6, pp. 805-807 [3 page(s) (article)] (16 ref.)
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