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1/78. Fatal pulmonary haemorrhage during anaesthesia for bronchial artery embolization in cystic fibrosis.

    Three children with cystic fibrosis (CF) had significant pulmonary haemorrhage during anaesthetic induction prior to bronchial artery embolization (BAE). Haemorrhage was associated with rapid clinical deterioration and subsequent early death. We believe that the stresses associated with intermittent positive pressure ventilation (IPPV) were the most likely precipitant to rebleeding and that the inability to clear blood through coughing was also an important factor leading to deterioration. Intermittent positive pressure ventilation should be avoided when possible in children with CF with recent significant pulmonary haemorrhage.
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2/78. Internal iliac artery embolisation for intractable bladder haemorrhage in the peri-operative phase.

    Intractable haemorrhage from the bladder wall during transurethral resection of bladder tumour is uncommon but potentially catastrophic. Internal iliac artery embolisation is a minimally invasive technique, which is now widely practised to stop bleeding from branches of these arteries is situations including pelvic malignancy, obstetric and gynaecological emergencies and trauma. We report its successful use peri-operatively, in an unfit, elderly patient with uncontrolled bleeding.
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keywords = haemorrhage
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3/78. 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.
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keywords = haemorrhage
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4/78. Anaesthetic management of liver haemorrhage during laparotomy in a premature infant with necrotizing enterocolitis.

    The case of a 680 g premature baby who developed massive spontaneous liver haemorrhage during laparotomy for necrotizing enterocolitis is reported. The infant survived due to rapid and massive fluid administration, including transfusion of large volumes of blood and blood products, in combination with high dose inotropic support and the surgical use of packing with thrombostatic sponges. Good venous access, including two central venous lines, turned out to be very useful.
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ranking = 0.83333333333333
keywords = haemorrhage
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5/78. Anesthetic implications of the grey platelet syndrome.

    PURPOSE: To describe the obstetrical anesthetic care provided to two sisters with a rare qualitative platelet disorder, the grey platelet syndrome (GPS). CLINICAL FEATURES: Both patients manifested thrombocytopenia prior to delivery without previous history of a bleeding diathesis or other abnormal laboratory tests of coagulation function. The first required emergency cesarean section due to fetal bradycardia. Due to the thrombocytopenia and the emergency nature of the procedure, general anesthesia was used. During the C-section, 1.5-2 litres of old blood was noted in the abdominal cavity which was attributed to an old splenic capsular tear of unknown etiology. work-up for the thrombocytopenia revealed large platelets on the peripheral smear with abnormal aggregation on platelet function studies. Electron microscopy of the platelets revealed absent alpha granules, diagnostic of GPS. The second patient, the sister of patient #1, presented in a similar fashion. However, at presentation, the platelet count was 112,000 x m(-3) and spinal anesthesia was provided without complication for Cesarean delivery. The same patient presented for a second delivery during which fetal bradycardia necessitated emergency C-section under general anesthesia. Despite administration of six units of platelets, blood loss was 5,200 mL. Her postpartum course was uncomplicated and she and the infant were discharged home on postoperative day #4. CONCLUSION: The primary concerns for the anesthesiologist looking after patients with qualitative platelet defects are related to defective coagulation which influences the need for perioperative replacement of blood products and limits the use of regional anesthesia.
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ranking = 0.93272115061253
keywords = blood loss
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6/78. Iatrogenic injuries of renal pelvis and ureter following open surgery for urolithiasis.

    OBJECTIVE: To study the types of injuries of renal pelvis and ureter following open surgical procedures for urolithiasis and predisposing factors leading to such injuries and discuss various options for the management of iatrogenic injuries of the renal pelvis and ureter. patients AND METHOD: Case files and available radiographs of the patients who were managed for ureteral and renal pelvic injuries were reviewed. Initial procedure, mode of injury and clinical course were noted. RESULTS: The study consisted of 13 patients (9 males and 4 females). Age of the patients ranged from 18 to 65 years. Eight patients had injuries of renal pelvis or ureteropelvic junction and 5 patients got ureteral injuries. Primary management of ureteral and renal pelvic injuries was successful in 9 patients. Four patients required further surgery. Three out of 4 patients underwent nephrectomy and in 1 patient renal function deteriorated despite secondary pyeloplasty. Among 3 patients who had nephrectomy, one died postoperatively due to sepsis and haemorrhage. CONCLUSION: Injuries of the renal pelvis and ureter have significant morbidity and even mortality. Peroperative recognition of these injuries and appropriate management can prevent the late sequele of these injuries such as stricture formation leading to progressive renal damage.
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keywords = haemorrhage
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7/78. Aortic injury during laparoscopic fundoplication: an underreported complication.

    BACKGROUND: Advances in video equipment, instrumentation, and laparoscopic skills have enabled the performance of an increasing variety of procedures using minimally invasive techniques. Additionally, the public is more aware of the benefits of laparoscopic surgery, including decreased postoperative pain and shortened recovery period. Surgical treatment of gastroesophageal reflux disease (GERD) is blossoming as a result. As with all surgical procedures, complications can occur. This case report describes a complication of laparoscopic fundoplication not previously reported. Also summarized is a review of all complications associated with minimal access fundoplication reported in the literature. methods: After appropriate evaluation for surgical treatment of GERD that revealed a nonspecific esophageal motility disorder, a 52-year-old female underwent laparoscopic Toupet fundoplication. During the procedure, a needle injury occurred to the aorta at the level of the hiatus. Despite exploration during the original procedure, which had been converted to laparotomy, and at two subsequent operations, the intermittent bleeding source was not found. The patient eventually died secondary to blood loss. The aortic injury was discovered postmortem. CONCLUSION: A variety of intraoperative complications associated with laparoscopic fundoplication have been reported, including gastric, esophageal, and bowel perforations, cardiac tamponade, pneumothorax, celiac artery thrombosis, bleeding, and death. Although this is the first reported aortic injury during minimally invasive fundoplication not related to trocar placement, discussion with other surgeons indicates that this is not the only occurrence of this complication.
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ranking = 0.93272115061253
keywords = blood loss
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8/78. Repair of a diaphragmatic injury during hand assisted laparoscopic nephrectomy using an onlay patch of polypropylene and polyglactin mesh.

    PURPOSE: We describe a simple and time efficient technique for repairing a diaphragmatic injury occurring during right hand assisted laparoscopic radical nephrectomy. MATERIALS AND methods: A dual layer polypropylene and polyglactin mesh was created extracorporeally by sewing a 2 x 2 piece of polypropylene mesh to a 2 x 2 piece of polyglactin mesh with 4, 4-zero interrupted polyglactin sutures. This dual layer was then positioned manually over the diaphragmatic rent and secured with a laparoscopic stapling device. A 16Fr chest tube was placed at the conclusion of the procedure. RESULTS: overall operative time was 3.5 hours with an estimated blood loss of 100 cc. Repair of the diaphragmatic injury extended operative time by 25 minutes. Extubation was done at the conclusion of the case and the chest tube was removed within 36 hours of the procedure. The patient was discharged home on postoperative day 3. At 14 months of followup the patient remained disease-free on radiography and without pulmonary or gastrointestinal sequelae. CONCLUSIONS: We describe a simple and time efficient technique for repairing diaphragmatic injury occurring during right hand assisted laparoscopy. This technique takes advantage of the manual and tactile sensation provided by the hand assistance device, provides a tension-free repair and avoids laparoscopic suturing.
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ranking = 0.93272115061253
keywords = blood loss
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9/78. Perioperative risk factors for posterior ischemic optic neuropathy.

    BACKGROUND: infarction of the optic nerve posterior to the lamina cribrosa, called posterior ischemic optic neuropathy (PION), is a condition that can result in profound bilateral blindness. Cases of PION treated at this institution and those described in the literature were analyzed to identify clinical features that profile those individuals at risk of PION in an attempt to identify major contributing factors that could be addressed prophylactically to enable effective prevention. STUDY DESIGN: Salient clinical features in seven cases of PION diagnosed at the Doheny eye Institute between 1989 and 1998 are compared with 46 cases of PION reported in the literature. RESULTS: In the Doheny series there were six men and one woman aged 12 to 66 years (mean, 47 years). Five patients were status-post spine surgery, one was status-post knee surgery, and one had a bleeding stomach ulcer. Vision loss was simultaneously bilateral in six of seven patients (85.7%) and was apparent immediately after surgery. There were no abnormal retinal or choroidal findings including diabetic retinopathy, in any of the patients. Notable contributing factors were blood loss in all seven patients, ranging from 2,000 to 16,000 mL, with a drop in hematocrit of 9.5% to 19% (mean, 14%), and intraoperative systemic hypotension in all patients. Facial edema was a factor in three of six spine surgery patients (50%). patients reported in the literature had a mean age of 50 years and were also predominantly men (34 of 46, 74%) who underwent spine surgery (30 of 46, 65.2%). CONCLUSIONS: Middle-aged men undergoing spine surgery with prolonged intraoperative hypotension and postoperative anemia and facial swelling are at risk of developing PION from hypovolemic hypotension. Avoiding or immediately correcting these contributory factors can reduce the incidence of PION.
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keywords = blood loss
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10/78. The use of vasopressin to treat catecholamine-resistant hypotension after phaeochromocytoma removal.

    A patient undergoing excision of phaeochromocytoma developed refractory hypotension which was complicated by significant intraoperative blood loss. Cardiovascular support with fluids, blood and noradrenaline failed to reverse the hypotension. Introduction of vasopressin successfully reversed the hypotension. The experience with this case suggests that vasopressin may be a useful adjunct in the treatment of catecholamine-resistant hypotension after phaeochromocytoma excision.
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ranking = 0.93272115061253
keywords = blood loss
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