1/156. 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 = disease (Clic here for more details about this article) |
2/156. hypotension, bradycardia, and asystole after high-dose intravenous methylprednisolone in a monitored patient.We report a case of hypotension, bradycardia, and asystole after intravenous administration of high-dose methylprednisolone in a 73-year-old patient who underwent electrocardiographic (ECG) monitoring throughout the episode. There was a history of ischemic cardiac disease 9 years earlier. The patient was admitted with a pulmonary-renal syndrome with hemoptysis, rapidly progressive renal failure, and hypoxemia that required mechanical ventilation in the intensive care unit. After receiving advanced cardiopulmonary resuscitation, the patient recovered cardiac rhythm. The ECG showed a junctional rhythm without ventricular arrhythmia. This study reviews the current proposed mechanisms of sudden death after a high dose of intravenous methylprednisolone (IVMP). These mechanisms are not well understood because, in most cases, the patients were not monitored at the moment of the event. Rapid infusion and underlying cardiac disease were important risk factors in the case reported here, and the authors discount ventricular arrhythmia as the main mechanism.- - - - - - - - - - ranking = 2keywords = disease (Clic here for more details about this article) |
3/156. Uremic autonomic neuropathy: evaluation of ephedrine sulphate therapy for hemodialysis-induced hypotension.The hemodynamic response to ephedrine sulphate were studied in a patient on maintenance hemodialysis therapy with chronic renal failure due to renal amyloidosis. The evaluation (including cardiac catheterization studies) and estimation of responses to Valsalva maneuvers before and after ephedrine administration documented the diagnosis of autonomic insufficiency. Oral ephedrine failed to influence the episodes of severe dialysis-induced hypotension. Also the patient did not benefit from the infusion of Aramine. These studies suggest that catecholamine stores of adrenergic nerves may be depleted in uremic patients with clinical signs of autonomic neuropathy.- - - - - - - - - - ranking = 0.53324560423684keywords = nerve (Clic here for more details about this article) |
4/156. Coronary artery spasm induced by trigeminal nerve stimulation and vagal reflex during intracranial operation.This report describes a case of ventricular fibrillation resulting from coronary vasospasm during intracranial operation under general anesthesia. An autonomic response associated with the intracranial procedure caused a coronary spasm, which was worsened by alpha-agonists. nitroglycerin effectively resolved the coronary spasm and co-complications persisted.- - - - - - - - - - ranking = 2.1329824169473keywords = nerve (Clic here for more details about this article) |
5/156. Clinical and physiological characteristics of autonomic failure with Parkinson's disease.We analyzed the clinical and physiological features of autonomic failure with Parkinson's disease (AF-PD) in seven patients and compared them with those of autonomic failure with multiple system atrophy (AF-MSA). In AF-PD, parkinsonism was more gradually progressive than in AF-MSA, and symptoms were responsive to L-dopa. All seven patients with AF-PD had orthostatic hypotension, postprandial hypotension, and constipation, but no urinary retention. Of these, three had hypohidrosis and five had frequent urination; five patients had subnormal plasma norepinephrine (NE) concentrations. Supersensitivity to NE infusion was observed in all patients. head-up tilting (HUT) test resulted in no increase of plasma NE concentrations in both groups, but a significant increase of the plasma arginine vasopressin (AVP) concentrations in the patients with AF-PD. Urodynamic studies revealed that urinary bladder function was relatively well preserved in AF-PD in contrast to AF-MSA. In conclusion, there exists some clinical and physiological differences in autonomic features between AF-PD and AF-MSA, and postganglionic involvement predominates in AF-PD.- - - - - - - - - - ranking = 5keywords = disease (Clic here for more details about this article) |
6/156. life-threatening haemorrhage following obturator artery injury during transurethral bladder surgery: a sequel of an unsuccessful obturator nerve block.In spite of prior blockade of the obturator nerve with 1% mepivacaine (8 ml) utilizing a nerve stimulator, violent leg jerking was evoked during transurethral electroresection of a bladder tumour approximately 1 h after the blockade in a 68-year-old man. The patient became severely hypotensive immediately following the jerking, and a large lower abdominal swelling concurrently developed. The urgent laparotomy indicated that the left obturator artery was severely injured by the resectoscope associated with the bladder perforation, causing acute massive haemorrhage. The patient recovered uneventfully after adequate surgery. Investigation of the literature suggested that both our nerve stimulation technique and anatomical approach were appropriate. It was therefore unlikely that our block resulted in failure because of an inappropriate site for deposition of the anaesthetic. However, consensus does not appear to have been obtained as to the concentration and volume of the anaesthetic necessary for prevention of the obturator nerve stimulation during the transurethral procedures. The concentration and volume of mepivacaine we used might have been too low and/or small, respectively, to profoundly block all the motor neuron fibres of the nerve. Alternatively, stimulation of the obturator nerve might occur because of the presence of some anatomical variant, such as the accessory obturator nerve or its abnormal branching. In conclusion, some uncertainty appears to exist in the effectiveness of the local anaesthetic blockade of the obturator nerve. In order to attain profound blockade of the motor neuron fibres of the obturator nerve and thereby prevent the thigh-adductor muscle contraction which can lead to life-threatening situations, we recommend, even with a nerve stimulator, to use a larger volume of a higher concentration of local anaesthetic with a longer duration in the obturator nerve block for the transurethral procedures.- - - - - - - - - - ranking = 7.9986840635525keywords = nerve (Clic here for more details about this article) |
7/156. Acute vision loss in children with autosomal recessive polycystic kidney disease.patients with autosomal recessive polycystic kidney disease (ARPKD) often present with renal insufficiency and hypertension. We present two children with ARPKD and end-stage renal disease who developed anterior ischemic optic neuropathy and vision loss. Anterior ischemic optic neuropathy occurs rarely in children and has never been reported in children with ARPKD or end-stage renal disease. Both of our patients were chronically hypotensive and anemic, which are known risk factors for ischemic optic neuropathy.- - - - - - - - - - ranking = 7keywords = disease (Clic here for more details about this article) |
8/156. Cardiovascular collapse associated with extreme iatrogenic PEEPi in patients with obstructive airways disease.Chronic obstructive pulmonary disease (COPD) is commonly associated with positive alveolar pressure at end-expiration (intrinsic PEEP or PEEPi) caused by a prolonged expiratory time constant. Positive pressure ventilation (PPV) with large tidal volumes and high ventilatory frequencies may cause pulmonary hyperinflation, with increases in intrathoracic pressure and cardiopulmonary effects. We report two cases, one of fatal pulseless electrical activity, the other of life-threatening hypotension, both during vigorous manual PPV, in patients with severe COPD. This phenomenon has been well-recognized by intensivists but is reported poorly more widely.- - - - - - - - - - ranking = 5keywords = disease (Clic here for more details about this article) |
9/156. Predicting outcome from coma: man-in-the-barrel syndrome as potential pitfall.The glasgow coma scale motor score is often used in predicting outcome after hypoxic-ischemic coma. Judicious care should be exerted when using this variable in predicting outcome in patients with coma following hypotension since borderzone infarction can obscure the clinical picture. We describe a patient who underwent skull base surgery for a schwannoma of the left facial nerve. The operation, which lasted for 10 h, was conducted under controlled hypotension. After the intervention the patient remained comatose with absent arm movements upon painful stimuli. An absent motor score usually carries a poor prognosis. However, magnetic resonance inversion recovery imaging of the brain showed bilateral hyperintense lesions in the arm-hand area indicative of borderzone ischemic damage. The patient received optimal supportive care and after 17 days he regained consciousness with 'man-in-the-barrel syndrome', which also further improved over time.- - - - - - - - - - ranking = 0.53324560423684keywords = nerve (Clic here for more details about this article) |
10/156. Coma as an acute presentation of adrenoleukodystrophy.X-linked adrenoleukodystrophy is a metabolic disorder with broad clinical variations. A 4-year-old male admitted to the hospital with fever, hypotension, and coma as the presenting signs of adrenoleukodystrophy is reported. The initial presentation followed by rapidly developing disseminated intravascular coagulopathy and multiorgan failure suggested an initial diagnosis of septic shock. However, bronze skin pigmentation and a cranial computed tomography scan demonstrating posterior demyelination consistent with adrenoleukodystrophy led to the final diagnosis. The diagnosis was confirmed by the findings of elevated very-long-chain fatty acid levels and an elevated C24/C16 ratio in plasma and fibroblast cultures. Atypical presentations of the disease require a high index of suspicion to initiate treatment before the appearance of irreversible sequelae.- - - - - - - - - - ranking = 1keywords = disease (Clic here for more details about this article) |
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