1/2. Mirtazapine (Remeron) as treatment for non-mechanical vomiting after gastric bypass.Two morbidly obese patients are reported who underwent gastric bypass and suffered nausea and vomiting 1 month after the operation. endoscopy and upper GI series showed no evidence of stomal stenosis or other mechanical cause for a GI obstruction. Control of vomiting by current antiemetic drugs such as bromopride and ondansetrone was unsuccessful. The patients were then given Remeron Soltab (mirtazapine, Organon, brazil) 30 mg once per day orally for 2 to 8 months. nausea and vomiting disappeared within days after beginning the medication. Stomal stenosis is the main cause of vomiting after gastric bypass. After ruling out mechanical causes, other reasons for postoperative vomiting must be considered. Mirtazapine is a noradrenergic and specific serotonergic antidepressant, which blocks the 5HT3 receptor, leading to an antiemetic effect. It has successfully been used as an antiemetic drug in patients undergoing chemotherapy. We concluded that mirtazapine may be a successful option to treat non-mechanical postoperative vomiting in morbidly obese patients after gastric bypass.- - - - - - - - - - ranking = 1keywords = obstruction (Clic here for more details about this article) |
2/2. Obstructive sleep apnea uncovered after high spinal anesthesia: a case report.PURPOSE: To illustrate how a patient's previously undiagnosed obstructive sleep apnea was uncovered after administration of a spinal anesthetic with a high sensory blockade, and to discuss possible explanations for this occurrence and anesthetic implications. CLINICAL FEATURES: A 55-yr-old male presented for osteotomy and open reduction and internal fixation of his left femur secondary to malunion from a previous fracture. Past medical history consisted of hypertension, hypercholesterolemia, bipolar disorder, gastroesophageal reflux disease, and cluster headaches. A combined spinal-epidural technique was chosen. Isobaric bupivacaine 0.5% (15 mg), was provided for the spinal anesthetic, along with 1 mg iv midazolam for procedural sedation and 0.5 mg iv droperidol for mild nausea. Throughout the operation, many apneic events were noted, often with respiratory efforts. The patient was easily arousable during each event and would breathe normally until the next episode. vital signs remained stable throughout. Postoperative respirology consultation was requested, and a sleep study revealed severe obstructive sleep apnea. The patient was subsequently started on continuous positive airway pressure with marked improvement in symptoms, including the cluster headaches. CONCLUSION: Recent literature suggests that high spinal blockade can result in altered levels of arousal by producing a de-afferentation of peripheral proprioceptive and sensory stimuli necessary for maintaining an awake state. In patients predisposed to upper airway obstruction, decreasing the level of consciousness can result in airway obstruction as occurs during sleep in these patients. This serves to underline the importance of considering capnography for all cases utilizing a neuraxial anesthetic technique.- - - - - - - - - - ranking = 2keywords = obstruction (Clic here for more details about this article) |