Delayed hypoxemia after bone cement insertion during total hip replacement under spinal anesthesia--a case report

We report a case of delayed hypoxemia in an aged healthy male patient, which developed 2 hours after cementation of the prosthesis in total hip replacement (THR) under spinal anesthesia. The patient was doing well throughout the operation but unfortunately, progressive tachypnea was noted 1 h after he was transferred to the recovery room (i.e. 2 h after the application of bone cement into the femur). An hour further, distinct wheeze was heard bilaterally on auscultation, which signified bronchospasm. Arterial blood gases analysis revealed a low PaO2 of 71 mmHg and a decrease of oxygen saturation to 91% with supplement of fractional oxygen of 35%. Aerosolization of bronchodilator with terbutaline was administered and supplemental fractional oxygen was increased to 50%. Although wheezing soon subsided, tachypnea and desaturation persisted. He was then transferred to the surgical intensive care unit for further management. Ventilation-perfusion lung scan was performed, which was suggestive of multiple pulmonary embolism.     

Red Man's syndrome following administration of vancomycin in a patient under spinal anesthesia--a case report

Prophylactic antibiotics are frequently administered during anesthesia to reduce the incidence of infection. The most common organisms revealed in wound infections are staphylococci. Vancomycin is the antibiotic of choice for resistant staphylococcal infections and bacterial endocarditis in patient allergic to penicillin. We had a case of tibial osteomyelitis, while undergoing removal of implants under spinal anesthesia developed hypotensions, bradycardia, consciousness change and skin erythematous macular rash after 0.1% vancomycin slow infusion for 10 min. After appropriate management, the patient recovered well and was discharged on the following day. Our report is intended to alert our colleagues that vancomycin can cause hypotension secondary to histamine release, direct myocardial depression and direct peripheral vasodilation. Even cardiac arrest had been reported in the literatures.     

Delayed acute spinal cord injury following intracranial gunshot trauma: case report

The authors report the case of a patient who presented with a hoarse voice and left hemiparesis following a gunshot injury with trajectory entering the left scapula, traversing the suboccipital bone, and coming to rest in the right lateral medullary cistern. Following recovery from the hemiparesis, abrupt quadriparesis occurred coincident with fall of the bullet into the anterior spinal canal. The bullet was retrieved following a C-2 and C-3 laminectomy, and postoperative MR imaging confirmed signal change in the cord at the level where the bullet had lodged. The patient then made a good neurological recovery. Bullets can fall from the posterior fossa with sufficient momentum to cause an acute spinal cord injury. Consideration for craniotomy and bullet retrieval should be given to large bullets lying in the CSF spaces of the posterior fossa as they pose risk for acute spinal cord injury.     

Dissociative amnesia after general anesthesia--a case report

Psychogenic unconsciousness is a rare cause of failure of prompt recovery from general anesthesia. The diagnosis is only made by exclusion of other conditions. We describe a young, healthy female who failed to wake up promptly after total intravenous anesthesia with alfentanil and propofol. She regained consciousness 24 hours later without any specific treatment. However she sustained amnesia for a period of 48 hours. Dissociative disorder was diagnosed after an extensive workup. This case report emphasizes the importance of inclusion of psychiatric disorder in the differential diagnosis should unexplainable delayed emergence from general anesthesia occur.     

Temporary hearing impairment after general anesthesia--a case report

The incidence of hearing impairment after anesthesia is rare. We report a case who received left total knee and hip replacement and developed severe hearing impairment of the left ear after general anesthesia. Examination of the left ear by an otolaryngologist showed that there was no noticeable abnormality. The hearing acuity recovered gradually and returned to normal 3 days later. The use of nitrous oxide during anesthesia was incriminated as the possible cause.     

Normal pressure hydrocephalus found after anesthesia--a case report

Normal pressure hydrocephalus (NPH) is characterized by insidious onset and gradual development of the triad of gait disturbance, dementia, and urinary incontinence. Nausea, vomiting, and signs of increased intracranial pressure do not occur. A 71-year-old male patient was scheduled for total knee replacement due to osteoarthritis of right knee joint. No neurological symptoms and signs except mild forgetfulness were detected during physical examination following admission. Due to operational mistakes, the anesthesiologist was informed that the surgery was cancelled just after completion of induction of general anesthesia. The patient was allowed to emerge from anesthesia. Unfortunately, his consciousness became drowsy the next morning. After a series of examinations, he was at last diagnosed as a case of NPH principally by the brain computed tomography scan. So he was scheduled again but this time for vetriculoperitoneal (V-P) shunt. The patient regained consciousness after V-P shunt. From this case, we learned that NPH may remain in concealment in the patients we contacted in our daily practice. A vigilant physician should keep in mind that the presentation of gait disturbance, dementia, and urinary incontinence in a patient may indicate the likelihood of NPH.     

Delayed recovery following atracurium: a case report

A 41-year-old woman received a total of 19 mg (0.6 mg kg-1) of atracurium over a 2-h period of general anaesthesia for abdominal surgery. Spontaneous respiration could not be achieved with neostigmine reversal. The temperature was found to be below 35 degrees C, and this delay in recovery is attributed to unrecognized accidental hypothermia.     

Witnessed asystole during spinal anesthesia treated with atropine and ondansetron: a case report

Purpose

To present a case of asystole during spinal anesthesia that responded to atropine and ondansetron and to discuss the possible pathophysiology with special emphasis on the Bezold-Jarisch reflex and the role of 5-HT₃ receptors in mediating bradycardia and sympathoinhibition.

Clinical features

A 50-yr-old, 97-kg, healthy male presented for elective left high tibial osteotomy. Spinal anesthesia was induced uneventfully at L3–4 with 11.25 mg of hyperbaric 0.75% bupivacaine and morphine 0.25 mg. Thirteen minutes after induction, the incision site was infiltrated with 20 mL of 0.5% bupivacaine with epinephrine 5μg·mL^?1 for intraoperative hemostasis, resulting in an increase in heart rate from 74 to 90 beats·min^?1. Three minutes after infiltration of the incision site, the patient’s heart rate dropped to 48 beats·min^?1, accompanied by a blood pressure of 107/51 mmHg, SpO₂ 97%, and a sinus bradycardia on the electrocardiogram. The electrocardiographic complexes suddenly disappeared with loss of the pulse oximeter waveform. Pre-drawn atropine 0.6 mgiv and ondansetron 4 mgiv were administered within seven seconds of the event. After an asystolic period of 30 to 40 sec, but before chest compressions were initiated, vital signs returned to normal with no other sequelae.

Conclusion

Exogenous epinephrine may have triggered the Bezold-Jarisch reflex and subsequent asystole. It is postulated that the combination of atropine and ondansetron may have played a key role in resuscitation by blocking the serotonergic and cholinergic receptors in the afferent and efferent limbs of this vagally-mediated reflex.     

A case of asystole following povidone iodine administration

We present a case of asystole due to anaphylactoid reaction after vaginal disinfection with povidone iodine under epidural anesthesia combined with general anesthesia. A 71-year-old woman was scheduled to undergo total cystectomy due to vesical cancer, invading into the wall of the vagina. After induction of anesthesia, epidural injection with 10 ml of 1% lidocaine and cleansing the vagina with povidone iodine solution were done at the same time. Shortly thereafter, sudden hypotension and bradycardia and asystole occurred. Multiple doses of epinephrine, chest compression, transcutaneous pacing and defibrillation were required to restore her spontaneous circulation. The surgery was cancelled. She stayed a night at the intensive care unit, and was discharged without any neurological complications the next day. The serum concentration of histamine increased to 7.0 microg x l(-1), but that of tryptase was within normal ranges when spontaneous circulation returned. The serum concentration of total iodine increased to 57.9 microg x dl(-1), which did not reach the toxic level. These results suggest that the circulatory collapse was probably caused by anaphylactoid reaction to povidone iodine. Epidural anesthesia may have worsened the circulatory collapse.     

经皮椎体成形术后迟发胸椎管狭窄症1例

正患者,女,78岁,因"胸椎术后3年,腰痛伴双小腿酸胀3个月,加重2周"入院。3年前外院诊断为"T11椎体压缩性骨折"并行经皮椎体成形术,术后恢复良好,术后定期随访。3个月前无明显诱因出现腰痛伴双小腿酸胀,间歇性跛行,约100 m,以小腿后侧酸胀为主,下蹲休息可缓解,2周前上述症状加重,于附近医院就诊,经诊断为"腰椎间盘突出症""类风湿性关节炎"后,经抗风湿、脱水消肿、营养神     

Iatrogenic spinal infection following epidural anaesthesia: case report

We present a case of epidural spinal abscess as a rare complication of epidural anaesthesia and discuss the diagnosis and management of this condition in patients presenting without neurological deficit.     

Delayed akathisia and suicidal attempts following epidural droperidol infusion--a case report

Epidural administration of droperidol has been used to prevent postoperative nausea and vomiting (PONV) caused by opioids, but the adverse reactions were relatively neglected. We present a patient who received patient-controlled epidural analgesia (PCEA) with bupivacaine-morphine-droperidol mixture for one and half days following hemorrhoidectomy, developed paroxysmal adverse reactions of akathisia, dysphoria, and suicidal attempts 3 days after the initiation of the treatment. The use of droperidol in PCEA for prevention of nausea and vomiting therefore needs to be re-evaluated according to the serious side effects occurring in our case.     

Accidental subdural catheterization due to complication of epidural anesthesia--a case report

Although accidental subdural injection is a well-recognized complication of epidural block, only a mere handful cases have been substantially proven by radiological evidence. Here we report a case of subdural catheterization during the attempt of epidural anesthesia for a gynecological procedure. Its clinical course and radiological findings are compared with those of the cases previously reported in literature. Whenever there is the occurrence of widespread of sensory block together with respiratory distress and hemodynamic unstability following epidural injection of local anesthetic, a subdural injection should be considered in spite of a negative confirmation. Repeated subdural injection of a local anesthetic at the same site may predispose patients to serious morbidity. Therefore, we recommend that when a subdural injection is evident or suspected, reinsertion of the catheter in the epidural space via another entry or contemplation of a switch to another anesthetic technique is mandatory.