| PURPOSE: To describe the anesthetic considerations of a combined lung and liver transplant in a 14-yr-old girl with cystic fibrosis. CLINICAL FEATURES: A 14 yr-old girl with cystic fibrosis presented for combined liver and lung transplantation. Anesthetic management was complex in that the pulmonary, hemodynamic, and hematological changes after cardiopulmonary bypass and lung transplantation made the management of the subsequent liver transplant unique. We used a moderate dose fentanyl and isoflurane anesthetic with invasive monitoring including a pulmonary artery catheter. Upon reperfusion of the new liver our patient exhibited severe pulmonary hypertension that was associated with a decrease in cardiac output and systemic hypotension. Utilizing a pulmonary artery catheter, this episode was treated with an increase of prostaglandin E1 (PGE1) infusion to 0.025 microg x kg(-1) x min(-1) and the initiation of 3 microg x kg(-1) x min(-1) dobutamine. The pulmonary hypertension resolved and the cardiac output and blood pressure returned to baseline levels. CONCLUSION: The anesthetic considerations for a combined lung and liver transplant are complex because of the interactions and alterations in cardiovascular, pulmonary and hemostatic systems. The use of a pulmonary artery catheter was critical to the management of our patient because it allowed us to accurately treat an episode of hypotension occurring during liver transplantation. This episode was secondary to acute pulmonary hypertension which is common after pulmonary transplantation but unusual during liver transplantation. It is also critical that a team approach is used to consider all of the concerns of the multiple services managing these complex patients. ( info) |
12/892. intracranial hypotension with parkinsonism, ataxia, and bulbar weakness. OBJECTIVE: To describe a case of spontaneous intracranial hypotension with a previously unreported constellation of presenting features. DESIGN: Case report. SETTING: Tertiary care center. MAIN OUTCOME AND RESULTS: We describe a patient with intracranial hypotension who presented with a parkinsonian syndrome and later development of ataxia and prominent bulbar symptomatology. headache was not a feature of her initial presentation and was only reported after repeated questioning during later evaluations. magnetic resonance imaging of the patient's head revealed findings characteristic of intracranial hypotension. An [18F]fluoro-m-tyrosine positron emission tomographic scan showed normal striatal activity, suggesting intact presynaptic nigrostriatal function. Opening pressure on lumbar puncture was reduced at 40 mm H2O. A source of cerebrospinal fluid leakage was not identified on nuclear cisternography and the patient underwent lumbar epidural blood patching, which resulted in complete resolution of her signs and symptoms as well as in a marked improvement in her imaging findings. CONCLUSIONS: The clinical spectrum of intracranial hypotension can be broadened to include parkinsonism, cerebellar ataxia, and prominent bulbar dysfunction. As with more common manifestations of the disorder, these features may resolve after appropriate treatment. ( info) |
13/892. Reversal by vasopressin of intractable hypotension in the late phase of hemorrhagic shock. BACKGROUND: Hypovolemic shock of marked severity and duration may progress to cardiovascular collapse unresponsive to volume replacement and drug intervention. On the basis of clinical observations, we investigated the action of vasopressin in an animal model of this condition. methods AND RESULTS: In 7 dogs, prolonged hemorrhagic shock (mean arterial pressure [MAP] of approximately 40 mm Hg) was induced by exsanguination into a reservoir. After approximately 30 minutes, progressive reinfusion was needed to maintain MAP at approximately 40 mm Hg, and by approximately 1 hour, despite complete restoration of blood volume, the administration of norepinephrine approximately 3 micrograms . kg(-1). min(-1) was required to maintain this pressure. At this moment, administration of vasopressin 1 to 4 mU. kg(-1). min(-1) increased MAP from 39 /-6 to 128 /-9 mm Hg (P<0.001), primarily because of peripheral vasoconstriction. In 3 dogs subjected to similar prolonged hemorrhagic shock, angiotensin ii 180 ng. kg(-1). min(-1) had only a marginal effect on MAP (45 /-12 to 49 /-15 mm Hg). plasma vasopressin was markedly elevated during acute hemorrhage but fell from 319 /-66 to 29 /-9 pg/mL before administration of vasopressin (P<0.01). CONCLUSIONS: Vasopressin is a uniquely effective pressor in the irreversible phase of hemorrhagic shock unresponsive to volume replacement and catecholamine vasopressors. Vasopressin deficiency may contribute to the pathogenesis of this condition. ( info) |
14/892. Pneumoencephalus and convulsions after ventriculoscopy: a potentially catastrophic complication. A nine-year-old boy with hydrocephalus underwent ventriculoscopy under general anesthesia. After introduction of ventriculoscope the patient had sudden bradycardia, hypotension, and shrinkage of ipsilateral cerebral hemisphere. The ventriculostomy was abandoned. At the end of anesthesia and endotracheal extubation, the patient developed generalized convulsions. Reexploration of wound did not reveal anything significant; however, postoperative CT scan of head showed massive pneumoencephalus. The patients received elective ventilation of lungs for 24 hours and made complete recovery. The authors describe the reasons for these complications and further management. ( info) |
15/892. 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. ( info) |
16/892. 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. ( info) |
17/892. 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. ( info) |
18/892. Radiofrequency catheter ablation in a haemodynamically compromised premature neonate with hydrops fetalis. A preterm infant was born at 35 weeks gestation after failed antenatal antiarrhythmic therapy. The infant had an incessant supraventricular tachycardia, impaired ventricular function and hypotension and failed to respond to adenosine, cardioversion and intravenous amiodarone. After resuscitation from cardiovascular collapse, a successful radiofrequency catheter ablation (RFA) of a left free wall atrioventricular pathway was performed at 24 h of age without extracorporeal support. The infant is normal on follow up at 12 months of age. Whilst most fetal and neonatal supraventricular tachyarrhythmias respond to antiarrhythmic medications and RFA is not required, this is the earliest RFA to be performed on a premature infant when antiarrhythmics have failed. ( info) |
19/892. Hypotensive ischemic optic neuropathy and peritoneal dialysis. PURPOSE: To report anterior ischemic optic neuropathy associated with systemic hypotension in a patient undergoing continuous ambulatory peritoneal dialysis. methods: Case report. A 58-year-old man undergoing continuous ambulatory peritoneal dialysis developed painless blurred vision in both eyes and bilateral optic disk swelling with an altitudinal field defect in the left eye. Twenty-four-hour ambulatory blood pressure monitoring was requested in addition to other routine investigations. RESULTS: Routine blood pressure measurement in the clinic was 130/86 mm Hg, but ambulatory blood pressure monitoring demonstrated pronounced early morning hypotension with individual readings as low as 91/41 mm Hg. CONCLUSIONS: renal dialysis can render patients hypotensive, and this may be associated with anterior ischemic optic neuropathy. The overnight drop in blood pressure may not be appreciated with routine blood pressure measurement. Therefore, 24-hour ambulatory blood pressure monitoring should be considered when investigating patients with suspected anterior ischemic optic neuropathy who are undergoing renal replacement. ( info) |
20/892. Possible venous argon gas embolism complicating argon gas enhanced coagulation during liver surgery. We report a case of a major venous argon embolism during argon beam coagulation of a liver biopsy. The essential signs were an abrupt reduction in end-tidal carbon dioxide partial pressure, in SpO2 and in systolic arterial pressure, at the time of coagulation. Spontaneous recovery was observed within 10 min. Precautions in respect of usage are highlighted. ( info) |