1/329. 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 = duct (Clic here for more details about this article) |
2/329. Intraoperative respiratory failure in a patient after treatment with bleomycin: previous and current intraoperative exposure to 50% oxygen.patients treated with bleomycin (BLM) are at risk of developing acute respiratory distress syndrome (ARDS) post-operatively, and this has been associated with high intraoperative concentrations of oxygen. We report progressive arterial desaturation noticeable 2 h after the start of a 4-h radical neck dissection for which the anaesthesia included 50% O2 in N2O. The patient had received two courses of bleomycin within the previous 2 months and had undergone an uneventful right hemiglossectomy under shorter but otherwise similar anaesthesia 4 weeks previously. His pulmonary function tests before the second procedure showed a slight depression of diffusing capacity (DLco) to 80% of predicted and minimal airway obstruction consistent with his history of smoking. The pulse oximetric reading during his second procedure reached 75%, but rose to 95% after treatment with methylprednisolone salbutamol and inspired O2 concentrations between 80% and 100%. By the end of the procedure, he satisfied the criteria for ARDS and was transferred to the ICU, where he developed bilateral pneumonia, deteriorated and died of multiple organ failure. This case suggests that the risk of hyperoxic pulmonary damage in patients exposed to bleomycin may increase not only with the degree and duration of hyperoxia in a given exposure, but also with the latent effects of recent previous exposure. Near normality of pulmonary function tests cannot be taken as reassurance, and small changes may have more adverse prognostic significance than in patients who have not been exposed to bleomycin.- - - - - - - - - - ranking = 2.0363351972202keywords = obstruction (Clic here for more details about this article) |
3/329. Efficacy of induced hypotension in the surgical treatment of large cavernous sinus cavernomas.OBJECT: cavernous sinus cavernomas are rare lesions associated with high rates of intraoperative mortality and morbidity resulting from profuse bleeding. In this paper, the authors report their experience in treating five patients with histologically confirmed cavernous sinus cavernomas and describe the efficacy of induced hypotension in facilitating excision of the lesion. methods: All five patients were women ranging in age from 25 to 54 years, with an average age of 42 years. The mass was small in one and large (>3 cm in diameter) in four. In one patient with a large mass, cardiac arrest occurred after the craniotomy, and remarkable reduction in the size of the cavernoma was evident on postmortem examination. The other three large lesions were successfully removed piecemeal after induction of hypotension (60-80 mm Hg systolic pressure), which remarkably reduced the mass and the bleeding during surgery. In the remaining patient, who had a small lesion, the cavernoma was removed in one piece. CONCLUSIONS: cavernous sinus cavernoma can be thought of as a cluster of sinusoidal cavities, the size of which varies depending on the systemic blood pressure. During surgery, reduction of the mass and control of bleeding from the cavernoma can be achieved by inducing hypotension, which enables the safe excision of this lesion. This technique should be considered by surgeons resecting a cavernous sinus tumor, especially when cavernoma is suspected.- - - - - - - - - - ranking = 3keywords = duct (Clic here for more details about this article) |
4/329. Pitfalls of undetected patent foramen ovale in off-pump cases.We describe pitfalls of a hitherto undetected patent foramen ovale during the conduct of an off-bypass coronary revascularization. Manipulation of the heart resulted in right-to-left shunt and severe desaturation requiring institution of cardiopulmonary bypass to close the patent foramen ovale and complete the revascularization.- - - - - - - - - - ranking = 1keywords = duct (Clic here for more details about this article) |
5/329. dna polymorphism analysis in transfusion-associated graft-versus-host disease.During cardiac surgery for transposition of the great arteries at age 7 weeks, a female infant received blood, fresh frozen plasma and platelet transfusions. Eleven days postoperatively, she developed bloody diarrhoea, fever, an erythematous macular rash, hepatomegaly, seizures and pancytopaenia. A clinical diagnosis of transfusion related graft-versus-host disease (GVHD) was supported by skin histopathology. dna polymorphism studies confirmed that circulating lymphocytes in peripheral blood and infiltrating cells in the skin were foreign in origin and were derived from transfused blood cells. No underlying immunodeficiency was identified. Treatment with steroids cyclosporin and antithymocyte globulin was unsuccessful and death occurred 2 months after surgery. The features of fever, rash, diarrhoea, liver dysfunction and pancytopaenia which characterize GVHD may mimic drug reactions or viral infection. In addition to histological features on skin biopsy. dna polymorphism studies on skin and blood samples provide a unique and sensitive method to confirm GVHD. Irradiation of blood products should be considered for acutely compromised infants requiring urgent cardiac surgery.- - - - - - - - - - ranking = 1keywords = duct (Clic here for more details about this article) |
6/329. Undiagnosed Mirizzi's syndrome: a word of caution for laparoscopic surgeons--a report of three cases and review of the literature.The mirizzi syndrome is often undiagnosed before surgery and can carry a high risk of iatrogenic damage to the common bile duct when encountered during open or, especially, laparoscopic surgery. Endoscopic management has recently been reported, but this treatment can be performed only when there is a high index of suspicion based on clinical criteria that the condition is present and therefore suggests the indication for endoscopic retrograde cholangiopancreatography (ERCP). This is not always the case. Consequently, in a considerable percentage of patients, the syndrome is discovered only after the bile ducts have been damaged during surgery. Three cases of Mirizzi's syndrome were observed in our experience of 896 laparoscopic cholecystectomies (0.3%). All patients were without typical symptoms, and the syndrome was unsuspected in spite of preoperative intravenous cholangiography. All patients required conversion to an open procedure, with two injuries of the common bile duct (a complete transection and a tear) being promptly repaired. We conclude that when this syndrome is suspected or found during surgery, the surgeon should follow these guidelines: (1) perform intraoperative cholangiography when possible, even through the gallbladder wall; and (2) dissect the gallbladder from above and, if necessary, open it to extract the stone. Dissection of Calot's triangle should never be attempted. Great expertise is required to complete the operation laparoscopically. The reported cases in the literature refer to a high percentage of conversion, underlining the technical difficulties and making this syndrome, when undiagnosed and unsuspected, a real challenge for laparoscopic surgeons.- - - - - - - - - - ranking = 37.434280641156keywords = bile duct, bile, duct (Clic here for more details about this article) |
7/329. Critical obstruction of the right ventricular outflow tract by a primary hemangioendothelioma in a seven month old.A 7-month-old presented with failure to thrive and a murmur. echocardiography demonstrated a large mass in the right ventricular outflow tract, extending through the pulmonary valve. During anaesthetic induction this caused critical obstruction of the outflow tract and cardiac arrest. Pathological diagnosis showed the lesion to be a primary hemangioendothelioma. Despite surgical excision and steroid therapy, the mass continued to grow for a period of 8 weeks, but then began to regress spontaneously.- - - - - - - - - - ranking = 11.181675986101keywords = obstruction, duct (Clic here for more details about this article) |
8/329. Inverted left atrial appendage presenting as a left atrial mass after cardiac surgery.Inversion of the left atrial appendage can masquerade as a new left atrial mass. Failure to be aware of this entity can result in unnecessary diagnostic and therapeutic procedures. If the entity is diagnosed intraoperatively, treatment is simple with external reduction and ligation.- - - - - - - - - - ranking = 1keywords = duct (Clic here for more details about this article) |
9/329. Localized intraoperative cardiac tamponade.A 65-year-old lady had undergone mitral and aortic valve replacement following an open mitral valvotomy and aortic valve exploration 5 years earlier. At reoperation, following sternotomy, extensive adhesions were encountered and it was decided to perform minimal dissection of the heart. Both the aortic and mitral valves were replaced using 23 mm and 29 mm St. Jude bileaflet valves, respectively. At the end of the procedure it was difficult to wean the patient off bypass as her mean arterial pressure dropped and the heart became dilated. It was found that a tamponade had developed, as a result of bleeding from the vent site in the pulmonary artery, and dissected a plane between the heart and the adherent pericardium. Her condition improved dramatically as the tamponade was released and she came off cardiopulmonary bypass with no inotropic support.- - - - - - - - - - ranking = 1.6233539518656keywords = bile (Clic here for more details about this article) |
10/329. Aortic obstruction caused by device occlusion of patent arterial duct.A 2 year old girl is reported in whom deployment of the Amplatzer ductal occluder caused significant aortic obstruction, requiring surgical removal of the device. This case emphasises the need for careful echocardiographic and angiographic assessment of the position of the Amplatzer ductal occluder before and after detaching the device from its delivery system, with particular emphasis on the position of the aortic retention ring. Careful assessment of ductal anatomy must guide case selection.- - - - - - - - - - ranking = 17.181675986101keywords = obstruction, duct (Clic here for more details about this article) |
| | Next -> |