1/612. 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. ( info) |
2/612. Transient left posterior hemiblock during myocardial ischemia-eliciting exercise treadmill testing: a report of a case and a critical analysis of the literature. We describe a 75-year-old male patient with two-vessel coronary artery disease, who developed transient left posterior hemiblock (LPH) while undergoing an exercise treadmill test (ETT). The intraventricular conduction abnormality initially had the features of alternating LPH, which evolved to stable LPH prior to dissipating, and it occurred at the first minute of recovery. The exercise electrocardiogram and the associated thallium-201 myocardial perfusion scintigraphy (Tl) revealed severe reversible myocardial ischemia. This rare occurrence is discussed in the context of the observed coronary lesions, the distribution of the radionuclide-detected ischemia, and the previous experience from the literature. An insight regarding the low prevalence of transient LPH is afforded, since the described case derives from a series of 2,160 consecutive patients who underwent ETT in conjunction with Tl. Finally, a comment is provided on the complexities of deciphering the specific pathophysiologic mechanism(s) of transient LPH, occurring during ETT. ( info) |
3/612. Left ventricular end-diastolic extrasystole with pseudonormalization of a left bundle branch block unmasking inferior ischemia. An electrocardiogram tracing of a patient in conducted sinus rhythm with left bundle branch block is shown, in which occasional pseudonormalization of intraventricular conduction is seen. This event is attributed to ventricular fusions with end-diastolic extrasystoles of the left His-Purkinje system distal to the block site. This type of extrasystole is discussed. In this case, normalization of ventricular activation allowed for diagnosis of inferior subepicardial ischemia. ( info) |
4/612. 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. ( info) |
5/612. Left ventricular ischemia due to coronary stenosis as an unexpected treatable cause of paroxysmal atrial fibrillation. We present a patient with exercise-induced paroxysmal atrial fibrillation who was eventually scheduled for a Cox-maze operation due to persistence of his complaints of fatigue, impaired exercise tolerance, and predominantly exercise-related irregular palpitations despite treatment with several antiarrhythmic drugs. A preoperative exercise stress test without antiarrhythmic or negative chronotropic drugs, however, showed clear evidence of myocardial ischemia. After coronary angioplasty of a significant stenosis in the left anterior descending artery, there was no recurrence of atrial fibrillation during a follow-up of 7 months. ( info) |
6/612. Prehospital epinephrine overdose in a child resulting in ventricular dysrhythmias and myocardial ischemia. INTRODUCTION: epinephrine overdoses in children have been associated with supraventricular tachycardia. myocardial ischemia subsequent to epinephrine overdose has not been reported in pediatric patients. CASE REPORT: We report a case of ventricular dysrhythmias and myocardial ischemia in a 5-year-old boy who received 10 times the recommended dose of subcutaneous epinephrine. Prehospital providers administered the epinephrine, believing it was part of a "high-dose" epinephrine protocol. DISCUSSION: There is no role for high-dose epinephrine in the treatment of allergic reactions or asthma. Careful epinephrine dosing, using mg/kg and verifying the volume, dilution, and route of administration is essential to prevent epinephrine toxicity. ( info) |
7/612. methemoglobinemia after axillary block with bupivacaine and additional injection of lidocaine in the operative field. methemoglobinemia may occur after the administration of various drugs, including some local anesthetics. We report a patient with chronic renal failure and ischemic heart disease who developed clinically significant methemoglobinemia after an axillary block with bupivacaine and additional injection of lidocaine in the operative field. Although the two local anesthetics usually do not cause methemoglobinemia, we suspect that the displacement of lidocaine from protein binding by bupivacaine, in combination with metabolic acidosis and treatment with other oxidants, was the reason for the development of methemoglobinemia. ( info) |
8/612. Significant complications can occur with ischemic heart disease and tilt table testing. We present an elderly patient who had syncope, with known coronary artery disease and a conduction abnormality. Because of a possible vasovagal reaction, the patient underwent a tilt table test prior to evaluation of ischemia or her LV function. During the tilt table test on isoproterenol, the patient developed ventricular fibrillation which was corrected immediately by cardioversion. Subsequently, the patient was found to have significant coronary artery disease which was treated with stenting and angioplasty. After treatment, there were no inducible arrhythmias on full dose isoproterenol. This case reports a significant complication that may occur when tilt table testing with isoproterenol and ischemia. ( info) |
9/612. Improvement of myocardial ischemia by subclavian stent implantation in patients with internal mammary grafts: a case report and review of the literature. In patients with coronary bypass which utilizes left (LIMA) or right internal mammary artery (RIMA), recurrent ischemia is often due to stenosis of the distal anastomoses of the grafts. However, occasionally, ischemia may be due to extracoronary causes, such as subclavian disease proximal to the internal mammary artery origins. This case report describes such clinical situation emphasizing the need for careful patient evaluation, and discusses therapeutic interventional options, in particular, safety and effectiveness of self expanding subclavian stent implantation. A review of the literature is also presented. ( info) |
10/612. Rotational atherectomy for left anterior descending artery septal perforator stenosis. Stenosis in large septal perforators can result in significant clinical ischemia. The distribution of the septal arteries is as large as many more commonly treated branch vessels. The interventricular septal blood supply has been ignored as a target for revascularization due to its inaccessibility for surgical revascularization, and the elastic recoil associated with balloon angioplasty in this location. Rotational atherectomy is a new therapeutic option for revascularization in this previously difficult location. The septal perforator ostium is the most common site of lesions and is functionally a branch ostial stenosis. We describe four cases in which rotational atherectomy was performed in patients with reversible ischemia due to septal artery stenosis. The acute angiographic results were stable, without evidence for immediate recoil. By debulking, facilitated angioplasty can yield stable acute results in this location. The small size of most septal branches and their angulated origin make rotational atherectomy challenging, and cases must be selected carefully. This previously ignored lesion location can be considered for revascularization in patients with suitable lesion and vessel morphology. ( info) |