1/28. Delayed akathisia and suicidal attempts following epidural droperidol infusion--a case report. Epidural administration of droperidol has been used to prevent postoperative nausea and vomiting (PONV) caused by opioids, but the adverse reactions were relatively neglected. We present a patient who received patient-controlled epidural analgesia (PCEA) with bupivacaine-morphine-droperidol mixture for one and half days following hemorrhoidectomy, developed paroxysmal adverse reactions of akathisia, dysphoria, and suicidal attempts 3 days after the initiation of the treatment. The use of droperidol in PCEA for prevention of nausea and vomiting therefore needs to be re-evaluated according to the serious side effects occurring in our case. ( info) |
| rupture of the oesophagus (Boerhaave's syndrome) is a rare complication of forceful or suppressed vomiting. postoperative nausea and vomiting is common but does not usually lead to life-threatening complications. A case of oesophageal rupture in a man who experienced postoperative nausea and vomiting after an uncomplicated procedure is described in this report. delayed diagnosis mandated conservative treatment. The clinical presentation, diagnosis and management of oesophageal rupture is discussed. ( info) |
| A young primigravid parturient had an uneventful labour under epidural analgesia and delivered a healthy male infant. She returned 48 hours later with fever, vomiting and severe headache, but was misdiagnosed as having endometritis. Further signs of meningitis appeared six hours later, however she succumbed to the infection and died four weeks later despite intensive care and high-dose antibiotic management. Causes of meningitis in the peripartum period are discussed. The possibility of a causal association between the patient's epidural analgesia and her infection are considered and preventive measures discussed. ( info) |
| methemoglobinemia is a condition characterized by increased level of methemoglobin in the erythrocytes and brownish cyanosis. Acquired methemoglobinemia is diagnosed by elevated methemoglobin with normal hemoglobin electrophoresis and normal NADH cytochrome b5 reductase. We report a patient who developed lethargy, confusion, and cyanosis during post-operative period. He had arterial methemoglobin level of 40.6% and oxygen saturation of 59%. No other cause could be found for his methemoglobinemia other than metoclopramide, even though it is rarely reported to cause methemoglobinemia in adults compared to infants. He had an excellent clinical response to treatment with methylene blue with which his clinical symptoms improved and the methemoglobin level returned to normal within 24 hours. Here we discuss the clinical features, diagnosis, and treatment of acquired methemoglobinemia induced by metoclopramide. ( info) |
5/28. Various presentations of postcholecystectomy bile leak diagnosed by scintigraphy. Hepatobiliary scintigraphy is an established method for the diagnosis of a bile leak from the biliary system. A bile leak should be considered in any patient after cholecystectomy who has unexplained abdominal pain after operation. Three patients with bile leak diagnosed by scintigraphy are described, one of whom had an unusual pattern of hepatic subcapsular collection of the bile. The second patient had a bile leak through the postsurgical drainage tube, whereas the third patient had a more typical pattern of leakage into the peritoneal cavity. ( info) |
6/28. Anaesthetic management of a patient with myotonic dystrophy. A 13-year-old boy with myotonic dystrophy underwent insertion of a percutaneous gastrostomy feeding tube under general anaesthesia. We used a laryngeal mask airway and a spontaneously breathing technique with propofol total intravenous anaesthesia. Postoperative vomiting and aspiration, 12 h after the procedure, subsequently required intubation and ventilation. We discuss the anaesthetic management of this case and review the features of the disease to be considered when contemplating anaesthesia in such patients. ( info) |
7/28. Concealed post-tonsillectomy haemorrhage associated with the use of the antiemetic tropisetron. A two-year-old child experienced concealed haemorrhage after adenotonsillectomy. In our patient, the absence of vomited or significant gastric blood and the presence of melaena stools may partly be attributed to prophylactic antiemetic treatment with tropisetron. This group of patients has a high incidence of postoperative nausea and vomiting, and antiemetic treatment is important and valuable. Rather than advocating the withholding of prophylactic antiemetic treatment, we suggest that whatever medication and techniques are used, good clinical care is dependent on careful postoperative observation and assessment for an appropriate period of time. ( info) |
8/28. Narcotic withdrawal syndrome following gastric bypass--a difficult diagnosis. BACKGROUND: It is common for bariatric patients to experience postoperative nausea, depression and remorse for several months following surgery. Difficulty exists for the surgeon in delineating the physical from the psychological in treating these patients. Preoperative education, evaluation and preparation, although essential, will not identify nor eliminate all potential problems. methods: We report the case history of a patient who ultimately underwent reversal of her gastric bypass. Her symptoms required multiple procedures and hospital admissions for what appeared to be anatomical problems. All procedures were done laparoscopically. RESULTS: The patient's main complaints of persistent nausea and abdominal pain combined with radiographic evidence of sub-optimal anatomic construct led to multiple operative procedures. Psychological intervention relative to the persistent nausea and abdominal pain was ineffectual, although the supportive and consistent nature of the psychotherapy relationship was useful in overall patient stability and emotional well being. Complete reversal of the bypass did not effect improvement. Ultimately, the diagnosis of narcotic withdrawal prompted the institution of methadone treatment with complete cessation of the symptoms of nausea and pain. CONCLUSIONS: The diagnosis of narcotic withdrawal syndrome can be difficult in the postoperative bariatric patient. Psychological evaluation and support are essential elements of the program throughout the entire course of a patient's treatment experience. Laparoscopic techniques simplified the surgical care of this patient. ( info) |
9/28. Excruciating perineal pain after intravenous dexamethasone. We describe two cases of unexpected perineal pain immediately after intravenous injection of fentanyl and dexamethasone (100 microg and 8 mg respectively) during induction of general anaesthesia. In both cases the pain was immediate (onset within 30 seconds), severe, localized to the genital region and of shooting and burning character No other clinical signs or symptoms were observed in either case and both patients made an uneventful recovery without neurological sequelae. We review the existing literature on perineal pain as an adverse effect of intravenous corticosteroid esters and recommend their administration either in diluted form or after induction of general anaesthesia. ( info) |
| The management of nausea and vomiting is fundamental to the post-operative nursing care of children. Children who have neurosurgical procedures, especially those that involve the posterior fossa, are likely to experience nausea and vomiting in the post-operative period. The proximity of brainstem emetic centres to the surgical site compounds the usual post-operative risk factors for nausea and vomiting. ondansetron is discussed as an agent that may be more effective than the traditionally-used antiemetics, such as dimenhydrinate and metoclopramide, in this population. nurses must advocate for effective therapeutic measures to manage children's post-operative nausea and vomiting. Advocacy requires knowledge of high-risk groups, accurate assessment, timely intervention, and thorough evaluation of pharmacological and non-pharmacological measures. ( info) |