Cases reported "Myocardial Ischemia"

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1/84. 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.
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ranking = 1
keywords = operative
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2/84. 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.
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ranking = 2
keywords = operative
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3/84. 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.
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ranking = 1
keywords = operative
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4/84. 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.
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ranking = 5
keywords = operative
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5/84. Anesthetic management of high-risk cardiac patients undergoing noncardiac surgery under the support of intraaortic balloon pump.

    patients with severely impaired left ventricular function, an uncorrectable coronary artery disease, and a recent myocardial infarction are at high risk of cardiac complications after major noncardiac surgery. We present two patients with extensive three-vessel coronary artery disease who underwent intraperitoneal surgery under the support of intraaortic balloon pump (IABP). In one patient, the IABP was inserted urgently because of the development of chest pain with significant ST depression on arrival in the operating room, and the other patient was managed with prophylactic IABP. There were no intraoperative or postoperative cardiac events in either patient. Thus, IABP should be considered in the perioperative management of patients with severe cardiac diseases.
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ranking = 3
keywords = operative
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6/84. Cardiogenic shock due to coronary narrowings one day after a MAZE III procedure.

    A MAZE III procedure was performed on a patient with a small body surface area. On the first postoperative day, the patient developed severe dysfunction of the left ventricle, due to significant narrowings of the right and circumflex coronary arteries in the areas that were cryoablated during the MAZE III procedure. The coronary narrowings were treated by percutaneous transluminal coronary angioplasty (PTCA). At discharge the coronary anatomy was normal again with an almost normal left ventricular function.
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ranking = 1
keywords = operative
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7/84. Prolonged perioperative myocardial ischemia in a young male: due to topical intranasal cocaine?

    We present a case of prolonged myocardial ischemia in a young healthy male presenting for nasal polypectomy and tonsillectomy. Induction of anesthesia proceeded uneventfully. Immediately after surgical incision, the patient developed a sinus tachycardia with ST-segment depression in leads II and III, and ST elevation in leads aVR, aVL, aVF, and V. Depth of anesthesia was increased, esmolol was administered, which slowed the heart rate, and the procedure was terminated. However, myocardial ischemia only gradually resolved, leaving residual T-wave flattening in lead III by day 3 postoperatively. After extensive investigation to rule out other causes of ischemia, we considered cardiotoxicity due to intranasally administered cocaine with epinephrine to be the most likely precipitant. Nasal packing with gauze soaked in a solution containing cocaine 3 mg/kg and epinephrine 1 mg occurred just 40 minutes prior to induction of anesthesia. Topical intranasal cocaine is rapidly and reliably absorbed systemically, with peak plasma concentrations occurring within 30 to 60 minutes, corresponding to the time course of cocaine administration and surgical stimulation in this patient. Systemic absorption of topical intranasal cocaine has previously been reported to cause adverse cardiac sequelae, including myocardial infarction. This report reinforces the need for caution regarding the use of topical intranasal cocaine, particularly if used in combination with epinephrine.
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ranking = 5
keywords = operative
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8/84. First clinical experience with the DeBakey VAD continuous-axial-flow pump for bridge to transplantation.

    BACKGROUND: A shortage of donor organs and increased numbers of deaths of patients on the waiting list for cardiac transplantation make mechanical circulatory support for a bridge to transplantation a standard clinical procedure. Continuous-flow rotary blood pumps offer exciting new perspectives. methods AND RESULTS: Two male patients (ages 44 and 65 years) suffering from end-stage left heart failure were implanted with a DeBakey VAD axial-flow pump for use as a bridge to transplant. In the initial postoperative period, the mean pump flow was 3.9 /-0.5 L/min, which equals a mean cardiac index (CI) of 2.3 /-0.2 L. min(-1). m(-2). In both patients, the early postoperative phase was characterized by a completely nonpulsatile flow profile. However, with the recovery of heart function 8 to 12 days after implantation, increasing pulse pressures became evident, and net flow rose to 4.5 /-0.6 L/min, causing an increase of mean CI up to 2.7 /-0.2 L. min(-1). m(-2). patients were mobilized and put through regular physical training. hemolysis stayed in the physiological range and increased only slightly from 2. 1 /-0.8 mg/dL before surgery to 3.3 /-1.8 mg/dL 6 weeks after implantation. CONCLUSIONS:The first clinical implants of the DeBakey VAD axial-flow pump have demonstrated the device to be a promising measure of bridge-to-transplant mechanical support.
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ranking = 2
keywords = operative
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9/84. Postoperative myocardial infarction in a patient with perioperative ST-depression--a case report.

    Often we ignore electrocardiogram (EKG) evidence of ischemia and no adverse events occur. However, once in a while these ischemic episodes will turn into a full-blown myocardial infarction. Therefore, studying perioperative events which tilt the balance over to postoperative myocardial infarction (PMI) can enlighten our knowledge in postoperative myocardial infarction (MI) prevention. We present a case of ST depression in perioperative EKG evolving into postoperative MI. In this paper we attempt to explore various possibilities which could have altered this patient from her ischemic state into an infracted event.
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ranking = 13
keywords = operative
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10/84. Thoracic epidural anesthesia for modified radical mastectomy in a patient with cryptogenic fibrosing alveolitis: a case report.

    A case of advanced cryptogenic fibrosing alveolitis (CFA) with multiple bullae and extensive pulmonary fibrosis, scheduled for modified radical mastectomy for carcinoma of breast, is presented. This patient had ischemic heart disease, corticosteroid-induced hypertension, diabetes mellitus, and a difficult airway. Thoracic epidural segmental anesthesia was successfully given to this patient. Preoperative problems, perioperative management, and alternative anesthetic techniques are discussed.
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ranking = 2
keywords = operative
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