Cerebral fat embolism diagnosed by magnetic resonance imaging at one, eight, and 50 days after hip arthroplasty: a case report

PURPOSE

To describe cardiovascular collapse during a cemented hip hemiarthroplasty in a patient who, despite a successful cardiopulmonary resuscitation, remained in a persistent vegetative state due to cerebral fat embolism diagnosed by magnetic resonance imaging (MRI).

CLINICAL FEATURES

A 75-yr-old woman with no medical history underwent cemented hip hemiarthroplasty under spinal anesthesia for a right femoral neck fracture. Shortly after insertion of the prosthesis, a sudden oxygen desaturation, hypotension, bradycardia, and cardiac arrest occurred. The patient was successfully resuscitated, but did not regain consciousness. The patient developed high-grade fever, thrombocytopenia, anemia, and oliguria. MRI scans of the brain revealed multiple high intensity signals throughout the white matter, the basal ganglia, the cerebellum, and the brain stem. The diagnosis of fat embolism was made on the basis of clinical findings and MRI images. Although her cardiorespiratory status improved over the next week, the patient remained in a persistent vegetative state.

CONCLUSION

When fat embolism is suspected, serial MRI scans of the brain should be performed to diagnose the etiology of cerebral embolism as well as to evaluate the severity of brain damage.

Multidisciplinary mechanical supports improve outcome in a shock patient with cardiac amyloidosis: a case report

Shock patients with restrictive cardiomyopathy due to cardiac amyloidosis are refractory to medical treatment. Here, we report a case of early initiation of intra-aortic balloon pumping (IABP) in a patient with cardiac amyloidosis who developed postoperative shock. Continuous hemodiafiltration was also applied to control circulating fluid volume. The mechanical treatments allowed reduction of the doses of catecholamine and diuretics and resulted in full recovery. It is reasonable to initiate IABP and hemofiltration dialysis during the early stages for the appropriate control of hemodynamics and fluid in shock patients with cardiac amyloidosis.

Arginine-vasopressin in neonates with vasodilatory shock after cardiopulmonary bypass

Successful therapy of vasodilatory shock in adults and children with arginine-vasopressin (AVP) has been reported previously. Data on the use of vasopressin in neonates is limited. This retrospective study reports the effects of AVP-treatment in neonates with catecholamine-resistant systemic vasodilatation after cardiopulmonary bypass. From March 2003 through December 2005, 172 neonates underwent open-heart surgery, 17 developed vasopressor-resistant hypotension and were treated with AVP. Thirteen patients had a stage I palliation of single ventricle, two had a Ross-operation and two had an arterial switch operation. All patients received multiple traditional inotropes and vasopressors prior to administration of AVP. AVP was started at median 0.0001 U x kg(-1) x min(-1) (range 0.00005-0.0002) and titrated up to a maximum of median 0.0003 U x kg(-1) x min(-1) (range 0.0001-0.001). AVP led to a significant increase in blood pressure (from 49+/-8 mmHg to 69+/-7 mmHg) and the requirement of traditional vasopressors decreased significantly. No peripheral vasoconstriction or ischemia was observed. Four of 13 patients, all with single ventricle palliation, died. In two patients death occurred due to additional complications 6 days after AVP was discontinued. One patient, who was still on AVP, died 42 hours postoperatively after prolonged hypoxemia not responding to inhaled nitric oxide. One patient arrested on the third postoperative day when AVP was almost weaned.

CONCLUSION

In neonates with vasodilatory shock after cardiopulmonary bypass AVP is a potent agent to increase blood pressure when traditional vasopressors are failing.

Profound vasodilatory hypotension in a patient with known empty sella syndrome following cardiac surgery

A 63-year-old female with known empty sella syndrome underwent coronary artery bypass grafting surgery. She became hypotensive immediately postoperatively and this did not respond to fluid resuscitation and inotropic therapy. Surgical re-exploration was undertaken and did not reveal any surgical cause. Pulmonary artery catheterisation confirmed a profound vasodilatory component to her shock. We believe this was due to unmasking of posterior pituitary hypofunction, in particular vasopressin insufficiency, due to metabolic stress. This rapidly corrected with an exogenous vasopressin infusion.

Steroid cover in dentistry: recommendations following a review of current policy in UK dental teaching hospitals

This article reports a project that was undertaken to determine current UK dental hospital policy with regard to the management of patients taking therapeutic doses of corticosteroids receiving dental treatment under local anaesthesia. There is variation in the medical management of this patient group, and whether practice should be standardized by means of a national policy document warrants consideration.

Antidiuretic hormone replacement therapy to prevent or ameliorate vasodilatory shock

Vasodilatory shock is a syndrome with high mortality. It is becoming evident that depletion of antidiuretic hormone (ADH) after cardiac surgery or during sepsis plays an important role in the pathogenesis of this condition. Established vasodilatory shock responds well to exogenous ADH infusion. It is possible that preventing ADH depletion at an earlier stage may abrogate the onset of vasodilatory shock, or at least reduce its severity. This paper examines the evidence supporting this concept, and the potential areas of concern in considering this particular type of hormone replacement therapy.

Vasopressin in the cardiac surgery intensive care unit

Although nearly 10% of patients experience profound vasodilatory shock after cardiopulmonary bypass, some patients remain refractory to traditional resuscitation. Among this subset are patients who have inappropriately low levels of endogenous vasopressin. Thus, vasopressin replacement is an intuitively attractive intervention. The purposes of this review are to outline the pathophysiology of vasodilatory shock after cardiopulmonary bypass, to discuss the physiological role of endogenous vasopressin, to explore the clinical basis for vasopressin replacement, and to review the pharmacology and dosing guidelines.

[Relative adrenocortical insufficiency in intensive care patients]

Unexplained shock developed after a major vascular operation in a man aged 67 who used inhalation corticosteroids for a chronic obstructive pulmonary disease, and after pancreaticoduodenectomy in a man aged 56. Both had relative adrenocortical insufficiency, combated with corticosteroid supplementation. The condition of a relative adrenocortical insufficiency is considered to exist if a test dose of corticosteroids leads to rapid weaning from sympathicomimetics. A subnormal rise of plasma cortisol after stimulation with adrenocorticotropic hormone supports the diagnosis. Routine corticosteroid substitution in intensive care patients is inadvisable, because it enhances the risk of complications related to use of steroids.

[Dorsal recumbency in dogs--a circulatory risk during surgical treatment?]

In this study, changes in hemodynamic, blood gas, and metabolic variables recorded during right lateral and dorsal recumbency in beagles anaesthetised with thiopental are presented. Other than reported in human beings, dorsal recumbency in these dogs resulted in an increase (33%) in heart rate, decrease (30%) in systolic, diastolic, and mean systemic arterial pressure, a decrease (17%) in systemic vascular resistance, and a decrease in both right (31%) and left (39%) ventricular work in comparison with lateral recumbency. Furthermore, mixed-venous PO2, oxygen saturation and respiratory quotient were lower in dorsal than in lateral recumbency while O2 consumption and lipolysis were increased in the former. The changes presented may have been caused by beta-adrenergic stimulation in dorsal recumbency. It needs to be studied if capillary perfusion can be maintained adequately during surgery in dorsal recumbency or if this predisposes to cardiovascular shock.

Cardiovascular collapse after laparoscopic liver biopsy

We describe a unique complication of laparoscopic liver biopsy. The increased intra-abdominal pressure associated with carbon dioxide pneumoperitoneum produced haemodynamic stability by tamponading a trochar-induced retroperitoneal haemorrhage. After deflation of the abdomen, release of the tamponade resulted in acute cardiovascular collapse. Other complications associated with laparoscopic surgery are also discussed.

Xanthine oxidase inactivation attenuates postocclusion shock after descending thoracic aorta occlusion and reperfusion in rabbits

"Declamping shock" is observed after aortic crossclamping, with hypovolemia, hypotension, and metabolic acidemia invariably present. We hypothesized that oxidants derived from xanthine oxidase influence the resuscitative interventions required to maintain baseline hemodynamic and acid-base status after aortic occlusion and reperfusion in rabbits. We also hypothesized that inactivation of xanthine oxidase with sodium tungstate could reduce systemic injury as assessed by the release of lactate dehydrogenase and alkaline phosphatase. To test these hypotheses, we established aortic occlusion in rabbits (n = 10, standard diet; n = 8, tungstate diet) for 40 minutes by inflation of a 4F Fogarty catheter in the descending thoracic aorta followed by 2 hours of reperfusion. Sham-operated rabbits (n = 10, standard diet; n = 9, tungstate diet) served as controls. Tungstate-pretreated rabbits required significantly less Ringer's solution (28%), phenylephrine (68%), and sodium bicarbonate (30%) during reperfusion (p < 0.005). Lactate dehydrogenase and alkaline phosphatase release during reperfusion was significantly attenuated by tungstate pretreatment (p < 0.05). Tungstate pretreatment resulted in plasma xanthine oxidase activities significantly lower than those in the sham group administered a standard diet (p = 0.007). Resuscitation requirements and systemic injury were reduced by inactivation of xanthine oxidase in a rabbit model that simulates the situation of human thoracic aorta operations.

Near fatal gas embolism during laparoscopic cholecystectomy

Laparoscopic cholecystectomy has been greeted with enthusiasm by surgeons and patients alike. However, with the passage of time reports of complications related to this new approach are being published. We report an unusual complication of gas embolism in laparoscopic cholecystectomy. A high index of suspicion along with vigilant intraoperative monitoring will help in the early diagnosis and reduction of morbidity associated with gas embolism.

Cardiovascular collapse during gynecologic laparoscopy complicated by pulmonary edema: report of a case

Although gynecologic laparoscopic surgery has recently become a routine and widespread operative procedure in Taiwan, the potential risks and complications in the clinical practice of laparoscopy should not be overlooked. Whilst the incidence of complications are rare, they can sometimes be serious, even life-threatening. This case report presents a woman with ruptured endometrioma, who developed sudden-onset cardiovascular collapse during laparoscopic procedure, in which carbon dioxide was used for insufflation. After resuscitation including cardioversion, her vital functions were restored; pulmonary edema developed soon afterwards but was resolved with conservative treatment. We discuss the possible causes of cardiovascular collapse during laparoscopic procedure and the management of resulting complications.

[Etiology, pathogenesis, clinical aspects, diagnosis and treatment of posttraumatic pancreatitis]

The authors generalize their experience in the treatment of 41 patients with posttraumatic pancreatitis. This complication predominated in the early postoperative period in patients with various degree of injury to the pancreas. The main etiopathogenic factors of the development of posttraumatic pancreatitis are indicated. The therapeutic tactics was mainly nonoperative. The effect was positive in 24 cases. Seventeen (41.5%) patients had the pyodestructive form. The mortality rate was 29.3%. The leading principle of management was the initial attitude towards all patients with injury to the pancreas as if they were potential patients with posttraumatic pancreatitis, and the prescription of preventive treatment.

[Severe postoperative pulmonary hypertensive crisis in a case of ventricular septal defect with Down's syndrome]

We encountered the episode of severe postoperative pulmonary hypertensive crisis in a case of ventricular septal defect with Down's syndrome. A 1 year 11 month old female with ventricular septal defect and pulmonary hypertension underwent open heart surgery. On the operative day after tracheal suction she experienced bradycardia, hypotension and pulmonary hypertension followed by shock condition. In spite of vigorous medical therapy clinical aspects were not improved. But only blood transfusion directly into the left atrium and administration of tolazoline hydrochlorides through pulmonary artery were very effective to improvement of hemodynamics and reduction of pulmonary hypertension. Moreover, after this episode pulmonary artery pressure showed elevation at the tracheal suction and the weaning from the respirator. We discussed the cause and treatment of postoperative pulmonary hypertensive crisis.

Caesarean section morbidity at district level in Zimbabwe

The incidence of complications related to Caesarean section was studied among 643 patients operated in four hospitals in Zimbabwe. Major complications were recorded in 15% of the patients and minor complications in 27%. Among these complications, infection morbidity played the leading role. Only 53% of Caesarean section were devoid of complication or need of blood transfusion. It is concluded that in a Third World environment, Caesarean section carries a substantial risk of operative and post-operative complications.

Obstructive jaundice blunts myocardial contractile response to isoprenaline in the dog: a clue to the susceptibility of jaundiced patients to shock?

Patients with obstructive jaundice are susceptible to postoperative shock. To clarify the mechanism of this phenomenon, we compared the contractile response to isoprenaline of isolated ventricular preparations from three groups of dogs: (a) dogs with chronic bile-duct ligation (CBDL), (b) dogs with choledochocaval anastomosis (CDCA) and (c) sham-operated dogs (SO). Isolated ventricular muscles from CBDL and CDCA dogs showed a depressed contractile response to isoprenaline as compared with SO dogs. Mechanical performance was spared in the CBDL and CDCA dogs. There were no differences in the contractile responses of SO and CBDL dogs, either to ouabain or to changes in the rates of stimulation (force-frequency relationships). These data demonstrate that, in the dog, obstructive jaundice and/or cholaemia are associated with blunted contractile response to beta-adrenoreceptor stimulation in the face of intact basic mechanical performance. Similar inotropic refractoriness to beta-adrenoreceptor stimulation could contribute to the susceptibility to postoperative shock in patients with obstructive jaundice.

[The TUR-syndrome and its importance to the anesthetist (author's transl)]

The so called TUR-syndrome is even today not to be underestimated a complication of the transurethral prostatectomy. In a retrospective study covering a time of three years and dealing only with transurethral prostatectomies under spinal anesthesia the frequency and degree of severity of the TUR-syndrome, the correlation between the early symptoms and the incidence and between the length of resection and the degree of severity of the syndrome were investigated. Furthermore the possibilities of prophylaxis and optimal therapy were inquired and recommendations were given for both of them. Finally it was pointed out, that since the first reports on the TUR-syndrome no really new aspects were gained in prophylaxis and therapy.

Unusual manifestations of penetrating cardiac injuries

Penetrating cardiac injuries frequently first appear in an unusual and insidious manner, and their diagnosis may not be immediately obvious. In a series of 20 cases of cardiac injury, ten cases were indicative of such subtle symptoms, several of which were life-threatening. These unusual manifestations can be categorized as early, intermediate, or late. Early problems of four patients included the following: (1) sudden onset of shock during laparotomy, performed due to apparent abdominal trauma; (2) cardiac arrest on arrival in the emergency room; and (3) cerebral air embolus and mimicked symptoms of possible irreversible anoxic brain damage. The intermediate manifestations of cardiac injury are usually discovered in the early recovery period, and include myocardial infarction with cardiogenic shock and bullet embolus to a peripheral artery. Intermediate manifestations were observed in two patients. Four patients had late complications that included pseudoaneurysm, ventricular septal defect, valvular damage, and recurrent pericarditis. These late complications were observed between one month and 21 years after cardiac injury. This indicates the necessity of long-term follow-up of these patients.

Homograft of the small intestine. Metabolic and functional changes causing irreversible shock

Homotransplantation of the small intestine is subject to high mortality in the first 48 hours after operation. We analyzed various causes of death, underlining the importance of postoperative shock, then developed an experiment in dogs with the object of improving the survival. We applied various therapeutic measures in order to reduce the factors which participate in the evolution of chronic, hypovolemic and toxic shock. We attempted to: (1) reduce the consecutive alterations to ischemia of the homotransplant during the non-perfusion period; (2) reduce the deleterious effect of retained fecal matter; (3) reduce the metabolic acidosis secondary to clamping of the great vessels; (4) acknowledge, analyze and correct alterations in fluid and electrolyte balances; (5) correct the blood volume; and (6) prevent infection. With these measures we have increased the survival rate.

Deaths associated with anaesthesia

The incidence of deaths associated with anaesthesia at Royal Prince Alfred Hospital for the period 1963-72 inclusive was 1:502. An analysis of the 408 deaths showed that more than half of them occurred in association with major cardiovascular and neurosurgical procedures. The number of deaths attributable to anaesthesia alone was 15 (3.7%). This was a marked reduction by comparison with the number in the previous decade (20.9%).