1/307. Suxamethonium and mivacurium sensitivity from pregnancy-induced plasma cholinesterase deficiency. A fit 36-year-old parturient received a general anaesthetic for manual removal of a retained placenta. She underwent rapid sequence induction of anaesthesia with suxamethonium, shortly followed by 10 mg of mivacurium. One hour later she had failed to establish adequate ventilation despite administration of drugs to reverse neuromuscular blockade. A provisional diagnosis of suxamethonium-related apnoea was made and her lungs were ventilated overnight on the intensive care Unit. plasma cholinesterase levels at the time were reduced to one-third of normal, with normal dibucaine and fluoride numbers. One month later her levels were back within the reference range. ( info) |
2/307. Postoperative apnoea following nivalin administration. Four patients developed postoperative apnoea after neuroleptanalgesia, and were given Nivalin whilst in an apnoeic state to reverse residual neuromuscular block. Neuromuscular transmission was monitored by a peripheral nerve stimulator, and recurarization was not observed. Central respiratory depression was the cause of postoperative apnoea. The possible mechanisms and the mode of prevention are stated in this paper. ( info) |
3/307. Haemoptysis after breath-hold diving. Pulmonary oedema has been described in swimmers and self-contained underwater breathing apparatus (Scuba) divers. This study reports three cases of haemoptysis secondary to alveolar haemorrhage in breath-hold divers. Contributory factors, such as haemodynamic modifications secondary to immersion, cold exposure, exercise and exposure to an increase in ambient pressure, could explain this type of accident. Furthermore, these divers had taken aspirin, which may have aggravated the bleeding. ( info) |
| anaphylaxis to chlorhexidine is rare. We report a patient who experienced anaphylaxis during a whole body bath with chlorhexidine. Early signs of a type I allergy may have been masked because of previous concomitant treatment with corticosteroids and PUVA. ( info) |
5/307. Mivacurium apnoea: a trap for the unwary. We present a case of unanticipated postoperative apnoea in a patient with associated medical illness to illustrate the diagnostic difficulty that can arise in the detection and subsequent management of mivacurium apnoea. A high index of suspicion is essential in the presence of concomitant medical conditions that may cause prolonged apnoea. To our knowledge, no report exists documenting the unanticipated occurrence of mivacurium apnoea in a patient with previously undiagnosed pseudocholinesterase deficiency and concomitant medical illness who has previously undergone 'balanced' general anaesthesia. ( info) |
6/307. Severe apnoeas following immunisation in premature infants. Four premature infants developed apnoeas severe enough to warrant resuscitation after immunisation with diphtheria, pertussis, and tetanus (DPT), and haemophilus influenzae B (Hib). One required re-intubation and ventilation. Although apnoeas after immunisation are recognised, they are not well documented. It is time for further research to elucidate the best time to immunise such infants. ( info) |
| The elimination of caffeine was investigated in a 1860 g, 31 week gestation neonate, following the accidental administration of a 160 mg.kg-1 dose. The first serum concentration measured was 217.5 mg.l-1 at 36.5 h after dosing. Fitting of time-concentration data was performed using non-linear regression with MKMODEL. A first order elimination model was superior to a mixed order model. Parameter estimates were: clearance 0.01 l.h-1, volume of distribution 1.17 litres, elimination half-life 81 h. Toxic manifestations included hypertonia, sweating, tachycardia, cardiac failure, pulmonary oedema and metabolic disturbances (metabolic acidosis, hyperglycaemia and creatine kinase elevation). An unusual feature of this infant's illness course was gastric dilatation. These signs resolved by day 7 at a serum concentration of 60-70 mg.l-1. caffeine clearance has traditionally been reported as either an absolute value or as directly proportional to body weight. The per kilogram model gives an erroneous impression that clearance is greatest in early childhood and then decreases with age until adult rates are reached in late adolescence. Age-related clearance values reported in the literature were reviewed using an allometric 3/4 power model. This size model demonstrates that clearance increases in infancy and reaches adult rates within the first three months of life. ( info) |
8/307. Lower limb exsanguination and embolism. We report a case of fatal pulmonary embolism during lower limb exsanguination in orthopaedic surgery. A 76-year-old woman underwent an open fixation of an external femoral condyle fracture one day after injury. Subarachnoidal anaesthesia was performed and Esmarch compression bandages were applied in preparation for tourniquet ischaemia. At this time, the patient lost consciousness, became apneic and collapsed. resuscitation procedures were instituted and transoesophageal echocardiography revealed pulmonary embolism. In spite of haemodynamic support and thrombolytic therapy, the patient died. Postmortem examination revealed multiple thromboemboli of recent origin in the right heart cavities, in the pulmonary arteries and in the popliteal and tibial veins of the injured leg. Preventive, diagnostic and therapeutic options of this catastrophic event and indications of pulmonary embolectomy are discussed. ( info) |
9/307. pH-dependent cocaine-induced cardiotoxicity. Severe cocaine toxicity causes acidemia and cardiac dysfunction. These manifestations are described in 4 patients who presented with seizures, psychomotor agitation, and cardiopulmonary arrest. Their initial laboratory values demonstrated acidemia and electrocardiographic findings that included a prolonged QRS complex and QTc duration and a rightward T40 ms axis deviation. Treatment of the patients with hyperventilation, sedation, active cooling, and sodium bicarbonate infusion led to the normalization of their blood pHs and reversal of their cardiac conduction disorders. Acidemia can contribute to cocaine cardiac disorders by promoting conduction delays, dysrhythmias, and depressed myocardial contractility. Good supportive care corrects the blood pH and cardiac conduction disorders and remains the major focus in the management of patients with cocaine toxicity. ( info) |
10/307. Recurrent acute life-threatening events and lactic acidosis caused by chronic carbon monoxide poisoning in an infant. Acute severe carbon monoxide poisoning is usually easy to recognize and diagnose. However, chronic or less severe exposure may produce more subtle symptoms. We report on a 31/2-year-old girl who was admitted to the hospital several times with acute, life-threatening events, acidosis, and flu-like symptoms. The diagnosis was elusive, but after careful questioning of family members and a home visit, chronic carbon monoxide poisoning was diagnosed. ( info) |