1/28. Fatal cardiac ischaemia associated with prolonged desflurane anaesthesia and administration of exogenous catecholamines.PURPOSE: Four cardiac ischaemic events are reported during and after prolonged anaesthesia with desflurane. CLINICAL FEATURES: We have evaluated desflurane in 21 consecutive patients undergoing advanced head and neck reconstructive surgery. Four deaths occurred which were associated with cardiac ischaemic syndromes either during or immediately after operation. All patients in the study received a similar anaesthetic. This comprised induction with propofol and maintenance with alfentanil and desflurane in oxygen-enriched air. Inotropic support (either dopamine or dobutamine in low dose, 5 micrograms.kg.min-1) was provided as part of the anaesthetic technique in all patients. Critical cardiovascular incidents were observed in each of the four patients during surgery. These were either sudden bradycardia or tachycardia associated with ST-segment electrocardiographic changes. The four patients who died had a documented past history of coronary heart disease and were classified American Society of Anesthesiologists (ASA) II or III. One patient (#2) did not survive anaesthesia and surgery and the three others died on the first, second and twelfth postoperative days. Enzyme increases (CK/CK-MB) were available in three patients and confirmed myocardial ischaemia. CONCLUSION: These cases represent an unexpected increase in the immediate postoperative mortality for these types of patients and this anaesthetic sequence.- - - - - - - - - - ranking = 1keywords = anaesthesia (Clic here for more details about this article) |
2/28. Profound bradycardia and hypotension following spinal anaesthesia in a patient receiving an ACE inhibitor: an important 'drug' interaction?An 86-year-old man on whom a transurethral resection of prostate was performed under spinal anaesthesia developed profound bradycardia and hypotension with disturbance of consciousness during transfer to the recovery room. Initial treatment with atropine produced rapid improvement in cardiovascular and cerebral function. A further hypotensive episode (without bradycardia) occurred approximately 1 h later but responded rapidly to methoxamine. The patient made a full recovery during an overnight stay on the High Dependency Unit. Possible mechanisms for this event are discussed, with the proposal that the concomitant administration of captopril and the relative unavailability of angiotensin ii may have significantly contributed to the problem.- - - - - - - - - - ranking = 0.83333333333333keywords = anaesthesia (Clic here for more details about this article) |
3/28. Anaesthesia for caesarean section in a patient with Eisenmenger's syndrome.Eisenmenger's syndrome was originally described in 1897 and redefined by wood in 1958. This syndrome includes pulmonary hypertension with reversed or bi-directional shunt associated with septal defects or a patent ductus arteriosus. A 27-year-old G2 PO with Eisenmenger's syndrome presented to the hospital for management at 17 weeks of pregnancy. She was advised termination of pregnancy but she refused. An elective caesarean section was performed successfully under general anaesthesia uneventfully at 29 weeks due to severe intrauterine growth retardation (IUGR). Patient's postoperative complications like pulmonary thromboembolism, the advantages and disadvantages of anticoagulation are discussed. pregnancy carries substantial maternal and fetal risk for patients with pulmonary hypertension and Eisenmenger's syndrome. Although pregnancy should be discouraged in women with Eisenmenger's syndrome it can be successful.- - - - - - - - - - ranking = 0.16666666666667keywords = anaesthesia (Clic here for more details about this article) |
4/28. Kinin-mediated anaphylactoid reaction implicated in acute intra-operative pulseless electrical activity.A 65-year-old patient undergoing total hip replacement under general anaesthesia suffered acute pulseless electrical activity with a fatal outcome. A kinin-mediated analphylactoid reaction following administration of a polygeline plasma expander (Haemaccel) was implicated by in vitro testing. This case report illustrates the diagnostic difficulties posed by non-histaminoid anaphylactoid reactions and the resistance to epinephrine of kinin-mediated hypotension.- - - - - - - - - - ranking = 0.16666666666667keywords = anaesthesia (Clic here for more details about this article) |
5/28. Total spinal anaesthesia in association with insertion of a paravertebral catheter.An association between intercostal nerve block and the development of a total spinal is rare. Usually, subarachnoid injection is considered to have followed intraneural placement or inadvertent entrance into a dural cuff extending beyond an intervertebral foramen. We report a patient that followed injection of local anaesthetic into a paravertebral catheter sited at surgery in the thoracic paravertebral space of a patient undergoing thoracotomy. This was a life-threatening event that occurred on two occasions before the definitive diagnosis was made. It is considered likely that the paravertebral catheter entered an intervertebral foramen and the tip perforated the dura.- - - - - - - - - - ranking = 0.66666666666667keywords = anaesthesia (Clic here for more details about this article) |
6/28. Acute heart failure during spinal surgery in a boy with Duchenne muscular dystrophy.patients with Duchenne muscular dystrophy (DMD) are at high risk of perioperative complications. DMD may be accompanied by heart failure resulting from dystrophic involvement of the myocardium, which can be subclinical in the early stages of the disease. This case demonstrates that a normal preoperative ECG and echocardiograph cannot exclude the development of heart failure during anaesthesia in DMD patients undergoing major surgery.- - - - - - - - - - ranking = 0.16666666666667keywords = anaesthesia (Clic here for more details about this article) |
7/28. Inadvertent extra-arachnoid (subdural) injection of a local anaesthetic agent during epidural anaesthesia. A case report.Profound hypotension occurring in a patient 2 hours after initiation of combined general and epidural anaesthesia for a myocutaneous free-flap graft was found to be attributable to subdural/extra-arachnoid injection of 0.5% bupivacaine. The initial diagnosis was based on a negative aspiration test, a delayed widespread sensory and sympathetic block, and the absence of any other obvious cause for the hypotension. This was confirmed by myelography, which demonstrated an extension of the contrast medium predominantly posteriorly in the spinal canal with excessive spread along the nerve roots. posture and coughing did not affect the spread.- - - - - - - - - - ranking = 0.83333333333333keywords = anaesthesia (Clic here for more details about this article) |
8/28. Intra-operative diagnosis of hypopituitarism in a patient undergoing radical nephrectomy.A 43-year-old woman presented for elective radical nephrectomy. After induction of anaesthesia, she developed hypotension that failed to respond to standard treatment measures. Her core temperature decreased to 34 degrees C in spite of active warming. She required very low concentrations of anaesthetic agents to maintain an adequate depth of anaesthesia for abdominal surgery. After excluding the common causes of hypotension, the possibility of subclinical hypopituitarism was considered and subsequently confirmed.- - - - - - - - - - ranking = 0.33333333333333keywords = anaesthesia (Clic here for more details about this article) |
9/28. Intraoperative anaphylaxis: verba volant, scripta manent!We describe a case of intraoperative gelatine-induced anaphylaxis whose diagnosis was delayed as the use of gelatine during surgical procedures was omitted for two times in patient's medical records. The subject is a 66-year old woman, with a negative medical history of atopy, food and drug allergy, with arterial hypertension on a course of beta-blockers and with bladder carcinoma requiring surgery. The patient had tolerated both general and local anaesthesia on several previous occasions. On the first occasion she experienced arterial fibrillation secondary to a severe episode of hypotension following local anaesthesia, while on a course of beta-blockers. On the second occasion she developed a very severe episode of hypotension followed by the outbreak of a generalised rash during general anaesthesia. The tryptase sera level was 109 mg/L one hour after the reaction had subsided, while the basal values were normal. On the third occasion the patient redeveloped severe hypotension and a generalised rash during general anaesthesia. The allergological work-up was negative, except for intradermal test with gelatine. A study of the intra-cellular cytokines in blood lymphocytes showed a production of IL4 from CD4 lymphocytes after stimulation by gelatine. The patient underwent a successive surgical procedure without any adverse event.- - - - - - - - - - ranking = 0.66666666666667keywords = anaesthesia (Clic here for more details about this article) |
10/28. Refractory hypotension during combined general and epidural anaesthesia in a patient on tricyclic antidepressants.We report a case of refractory hypotension that occurred after epidural injection of local anaesthetic, in a patient who was receiving tricyclic antidepressant therapy and was under general anaesthesia. The patient failed to respond to repeated injections of appropriate doses of sympathomimetics, but did respond to high-dose catecholamine infusions. We suggest that epidural anaesthesia should be used with care when combined with general anaesthesia for patients on long-standing tricyclic antidepressant therapy. If refractory hypotension should occur in such patients, the use of direct-acting vasoconstrictors such as noradrenaline should be considered.- - - - - - - - - - ranking = 1.1666666666667keywords = anaesthesia (Clic here for more details about this article) |
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