1/8. Anaesthetic considerations in a patient with lepromatous leprosy.PURPOSE: To consider the anaesthetic problems in a patient with lepromatous leprosy undergoing general anaesthesia. CLINICAL FEATURES: A 52 yr old man with lepromatous leprosy for five years was booked for elective radical nephrectomy. He received 100 mg dapsone per day po. The patient was asymptomatic for cardiovascular disease but his electrocardiogram showed complete left bundle branch block, inferior wall ischaemia with echocardiogram findings of 58% ejection fraction and left ventricular diastolic dysfunction. Other preoperative investigations (haemogram, serum urea and creatinine, liver function tests and chest X-ray) were normal. After premedication with diazepam, meperidine and promethazine, the patient received glycopyrrolate and anaesthesia was induced with thiopentone. atracurium was given to facilitate tracheal intubation. Anaesthesia was maintained with intermittent positive pressure ventilation using N2O in oxygen with halothane. Anaesthesia and surgery were uneventful except that the patient had a fixed heart rate that remained unchanged in response to administration of anticholinergic, laryngoscopy, intubation and extubation. CONCLUSION: patients with lepromatous leprosy may have cardiovascular dysautonomia even when they are asymptomatic for cardiovascular disease.- - - - - - - - - - ranking = 1keywords = anaesthesia (Clic here for more details about this article) |
2/8. 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 = 3keywords = anaesthesia (Clic here for more details about this article) |
3/8. Giant cervico-mediastinal lipoma. A clinical case.The lipoma is a circumscribed mesenchymal tumour originating from adipose tissue. The lesion is usually small and asymptomatic, and is most frequently located in the neck region. The case of a 77-year-old woman with chronic extrasystolic arrhythmia caused by a non-specified ischemic cardiopathy is reported. The woman presented a swelling at the front of her neck, observed for the first time about 6 months previously. This swelling progressively increased in size, provoking dysphagia, dysphonia, persistent cough, dyspnea, light jugular turgor and palpitations. Chest x-rays showed and opaque area at the front of the neck, which extended beyond the jugular incisure by about 2 cm. NMR of the neck showed a gross lipomatous formation at the front, mainly of the left, continuing in the front mediastinal region; the trachea was dislocated to the right and compressed at the back; the vasculo-nervous fasciculus, especially on the left, was compressed and enveloped by the adipose formation. The Holter test confirmed the presence of ventricular and supra-ventricular extrasystoles. Surgery was carried out under local anaesthesia because the displacement of the laryngo-tracheal axes precluded intubation. Histological analysis of the 9 x 4 x 2.2 cm mass confirmed the diagnosis of lipoma. After removal of the mass all the symptoms, which had been provoked by compression, as well as the cardiac arrhythmias disappeared. The prompt disappearance of the latter was particularly surprising. The possibility of the external compression of the nervous structures of the neck should be taken into consideration in cases of ventricular arrhythmia of unknown origin, and systematic study of the region carried out.- - - - - - - - - - ranking = 0.5keywords = anaesthesia (Clic here for more details about this article) |
4/8. Myocardial ischaemia precipitated by acute normovolaemic haemodilution.Acute normovolaemic haemodilution (ANH) is widely used as part of a blood conservation strategy to minimize the use of allogenic blood in the peri-operative period. Its role has not been proven in a prospective randomized trial. The potential benefits must not blind clinicians to the possible hazards. We report a life-threatening complication of ANH prior to induction of anaesthesia for aortic aneurysm repair.- - - - - - - - - - ranking = 0.5keywords = anaesthesia (Clic here for more details about this article) |
5/8. Severe myocardial ischaemia during mask induction of anaesthesia in an infant with unknown critical supravalvular aortic stenosis.Congenital supravalvular aortic stenosis is an uncommon type of aortic obstruction. When critical, it represents an extreme variant of outflow tract obstruction with increased risk of cardiovascular instability during exercise or anaesthesia. We present a case of severe myocardial ischaemia during induction of anaesthesia with sevoflurane in a 3-month baby with a presumed diagnosis of valvular aortic stenosis for which a percutaneous balloon dilatation of the aortic valve was scheduled.- - - - - - - - - - ranking = 3keywords = anaesthesia (Clic here for more details about this article) |
6/8. Levosimendan: a promising treatment for myocardial stunning?We report a case of a 55-year-old male undergoing major orofacial cancer surgery. A stent to the left anterior descending artery had been implanted for ischaemic heart disease 3 years previously. Twenty-four hours after uneventful anaesthesia and surgery, the patient developed myocardial infarction and cardiogenic shock. Immediate percutaneous transluminal coronary angioplasty, intra aortic balloon counterpulsation, and catecholamine therapy failed to stabilise haemodynamics. In light of successful reperfusion therapy and an only moderate elevation of troponin i, myocardial stunning rather than myonecrosis was considered to be the major contributor to life-threatening left ventricular failure. Therefore, the calcium-sensitising drug levosimendan, which exerts positive inotropic activity without increasing myocardial oxygen demand, was administered as a rescue medication. Within 24 h, levosimendan resulted in decreased filling pressures, reduced left ventricular end-diastolic volume, and augmented systemic pressures. Seven days following surgery, the patient was discharged from the intensive care unit in good clinical condition.- - - - - - - - - - ranking = 0.5keywords = anaesthesia (Clic here for more details about this article) |
7/8. Repeated episodes of myocardial ischaemia during combined thoracic epidural-isoflurane anaesthesia.A patient with a history of coronary artery diseases developed new ST segment depressions in the ECG registration during a low dose (0.7%) isoflurane anaesthesia that was combined with a continuous thoracic epidural analgesia. Simultaneously a small decrease in mean arterial blood pressure (MAP) was noted. During the next 5 min these changes were followed by a severe drop in MAP (from 88 to 60 mmHg) and in cardiac output from 5.5 to 3.2 L/min. When isoflurane was discontinued both the ECG and the cardiovascular changes returned to the previous condition. Later, when 0.5% isoflurane was restarted, the ECG changes reappeared within ten min, but disappeared once again when isoflurane administration was discontinued. Thus, this patient had repeated episodes of myocardial ischaemia which were associated with the use of low dose isoflurane. Although isoflurane-induced "coronary steal" may appear as a likely cause of these ischaemic episodes, it is possible that the thoracic epidural had synergistic action and rendered the patient exceptionally sensitive to minor changes in perfusion pressure.- - - - - - - - - - ranking = 2.5keywords = anaesthesia (Clic here for more details about this article) |
8/8. Treatment of milrinone-associated tachycardia with beta-blockers.PURPOSE: To describe a case of milrinone-associated tachycardia that was successfully treated with two beta-blockers. CLINICAL FEATURES: A 74-yr-old male patient underwent elective abdominal aortic aneurysm repair under combined epidural/general anaesthesia. He had a history of alcohol abuse, controlled hypertension and ischaemic heart disease. Postoperatively, the patient had persistent sinus tachycardia that was initially unsuccessfully treated with metoprolol. Subsequently, the patient's blood pressure and cardiac index decreased with an associated increase in pulmonary artery pressure. Analysis of the ST-segment revealed no evidence of myocardial ischaemia or infarction. These haemodynamic changes were treated with milrinone which exacerbated the baseline tachycardia without adverse blood pressure response. The subsequent administration of beta-blockers (esmolol and metoprolol) was successful in controlling the heart rate response to milrinone without adversely affecting the patient's haemodynamic profile. CONCLUSION: This report demonstrates the efficacy of esmolol and metoprolol for the treatment of milrinone-associated tachycardia, without compromising the haemodynamic effects of milrinone.- - - - - - - - - - ranking = 0.5keywords = anaesthesia (Clic here for more details about this article) |