Massive pulmonary embolism presented as sudden cardiac arrest in the immediate postoperative period after laparoscopic hysterectomy

A rare case of postoperative cardiac arrest in an otherwise healthy, 49-year-old female patient who had a laparoscopic hysterectomy, is presented. The cause of cardiac arrest was due to massive pulmonary embolism, which was detected by transesophageal echocardiography. Laparoscopic surgery is regarded as a less invasive procedure and provides a lower risk for postoperative complications. However, our is a case reminer that pneumoperitoneum may interfere with venous flow of lower extremities and predispose one to deep vein thrombosis or pulmonary embolism.     

Incidence and etiology of cardiac arrest occurring during the peroperative period and in the recovery room. Apropos of 102,468 anesthesia cases]

This study reviewed retrospectively 186 cardiac arrests (CA) observed in a series of 102,468 anaesthetics, carried out in a University Hospital between 1983 and 1987. Among them 29 were partly or totally related to anaesthesia and 11 had a fatal outcome. On the other hand, 157 CA (144 deaths) were not related to anaesthesia. Mortality rate due to anaesthesia was therefore 1.1 per 10,000. The main causes of anaesthesia related CA were overdosage, with or without hypovolaemia (9 CA, 6 of which occurred under regional anaesthesia); hypoxaemia (6 CA, 5 of which occurred under regional anaesthesia) and multifactorial sudden cardiac arrest (n = 8). The other aetiologies were: myocardial ischaemia (n = 3); anaphylactic shock due to propanidid (n = 1); protamine accident (n = 1); ventricular arrhythmia due to hypokalemia (n = 1). Fourteen CA occurred during induction (2 deaths), 14 during maintenance (8 deaths), and one during recovery. Risk factors for CA included a high ASA class, and the type of anaesthesia: there were 8 CA for 12,981 regional anaesthetics, and 21 for 89,487 general anaesthetics (p = 0.017). Emergency and paediatric anaesthesia were not risk factors. Outcome was independent of ASA class, but was related to aetiology: hypoxaemia (5 out of 6 recovered) and overdose with or without hypovolaemia (7 out of 8 recovered) had favourable outcomes. Furthermore, outcome of CA due to regional anaesthesia was satisfactory (7/8 recovered) (p = 0.08, NS). Such an analysis of the causes of anaesthetic disasters and their rate of occurrence can lead to more effective prevention.     

Systemic air embolism as a possible cause of cardiac arrest during endoscopic treatment of pulmonary haemangioma using a diode laser

Air embolism is a known but rare complication to endoscopic laser surgery. A case of nearly lethal air emboli as a complication to endoscopic laser surgery using a diode laser in the lungs is described. The case illustrates that even after prolonged resuscitation a successful outcome can be obtained.     

Dexmedetomidine-induced atrioventricular block followed by cardiac arrest during atrial pacing: a case report and review of the literature

Sinus bradycardia is a well-known consequence of stimulation of presynaptic α₂ adrenergic receptors due the adminstration of dexmedetomidine. One of the most serious adverse effects of dexmedetomidine is cardiac arrest. Some cases demonstrating such an arrest due to the indiscriminate use of this drug were recently reported. We continuously administered dexmedetomidine to a 56-year-old male patient at a rate of 0.3 μg/kg/h (lower than the recommended dose) without initial dosing for sedation in an intensive care unit. The patient had undergone open cardiac surgery and atrial pacing was maintained at a fixed rate, 90/min. The PQ interval in electrocardiography gradually prolonged during the infusion; finally, complete atrioventricular block and subsequent cardiac arrest occurred. Immediate cardiopulmonary resuscitation was carried out, including re-intubation, and recovery of spontaneous circulation was attained 15 min after the event. The patient was discharged from hospital on the 25th postoperative day without any neurological complications.     

骨科围手术期肺栓塞的诊断、治疗及预防

目的探讨骨科围手术期肺栓塞的诊断、治疗及预防策略。方法2000年9月～2004年12月收治13例骨科围手术期肺栓塞患者,分析肺栓塞高危因素、致病原因、发生时间、诊治流程及治疗结果,评价临床实用的早期诊断及治疗策略。结果2例术前发生肺栓塞者均死亡。术中1例发生肺栓塞者及时插管抢救溶栓后痊愈。术后10例发生肺栓塞患者中,1周内6例,2周内4例；4例经溶栓病情稳定后出院,继续口服华法林,随访3个月未再出现病情反复；6例死亡,其中5例栓塞后24h内死亡,1例72h死于二次栓塞。结论骨科围手术期肺栓塞的特点是发病急、症状重,救治不及时容易导致死亡。简单实用的早期临床诊治流程和个性化的预防措施是减少肺栓塞发生率,降低致残率和致死率的有效策略。     

Subcellular distribution of protein kinase C isozymes during cardioplegic arrest

BACKGROUND: On the basis of the hypothesis that cardioplegia-associated myocardial depression was due to activation of protein kinase C, we examined whether specific protein kinase C isozymes would translocate to a cellular fraction containing myofilaments. METHODS: Isolated rat hearts were perfused with Krebs-Ringer bicarbonate buffer for 30 minutes and arrested with 4 degrees C St Thomas No. 2 cardioplegic solution for 0 to 120 minutes (n = 5 per group). The 3 fractions of the left ventricle tissue represented the myofibrillar/nuclear fraction (P1), membranes (P2), and cytosol (supernatant). The distributions of protein kinase C isozymes alpha, delta, epsilon, and eta were examined after separation by electrophoresis, immunoblotting/chemiluminescence, and densitometry. RESULTS: A significant increase in protein kinase C-delta in the P1 fraction was detected after 5 minutes of cardioplegic arrest and remained increased for 60 minutes. Increases in P1 protein kinase C-alpha and -epsilon were seen transiently at 5 minutes, and protein kinase C-epsilon demonstrated a secondary increase in P1 at 30 to 60 minutes. There was also a significant relative increase in protein kinase C-alpha and protein kinase C-delta in the P2 fraction after 60 minutes of cardioplegia. CONCLUSIONS: These data are consistent with our hypothesis that activation of protein kinase C isozymes is associated with altered myofilament function after cardioplegic arrest.     

Surgical treatment for chronic pulmonary thromboembolism in a patient with protein C deficiency

Medical therapy for chronic pulmonary thromboembolism is limited, and surgical treatment has become more frequent recently. We have performed pulmonary thromboendarterectomy on a patient with chronic pulmonary thromboembolism accompanied by protein C deficiency. The patient was a woman aged 68 years who had protein C deficiency. The preoperative condition was New York Heart Association functional class IV. Hypoxemia, marked pulmonary hypertension, and low cardiac output were observed. After a median sternotomy, moderate hypothermia was induced using a cardiopulmonary bypass, and thromboendarterectomy in the pulmonary artery was performed. The arterial blood oxygen concentration improved, and the mean pulmonary pressure decreased. The cardiac output also increased, and New York Heart Association functional class improved to I. Pulmonary thromboendarterectomy under cardiopulmonary bypass was effective for chronic pulmonary thromboembolism accompanied by protein C deficiency.     

Cardiac arrest during anesthesia and the recovery period. Data from the INSERM survey 1978-1982

This report analyses rate, predisposing factors, causes and outcome of 458 cardiac arrests occurring during anaesthesia and the following 24 hours and collected in France by a national prospective survey between 1978 and 1982. The overall rate of cardiac arrests was 1 per 433 anaesthetics, resulting in death before the 24th postoperative hour in 79% of cases, i.e. 1 per 547 anaesthetics. Cardiac arrests not related to anaesthesia were three times more frequent than those related to anaesthesia. Among these, one half is partially related to anaesthesia and the other totally. The prognosis of cardiac arrests totally related to anaesthesia is six times better than that of not related arrests (64% of recoveries without sequelae vs 10%). The cardiac arrests not related to anaesthesia occur mainly at the end of surgery and the following 24 hours. The main causes are hypovolaemia, sepsis and severity of surgical illness. Among cardiac arrests related to anaesthesia, a quarter occurred during induction, another during maintenance and a half during recovery from anaesthesia. The first were mainly related to histamine release and had the lowest mortality rate. The last were mainly related to unrecognized postoperative respiratory depression and resulted in the highest mortality. The authors underline the necessity of better preoperative detection of high risk patients, smooth induction of anaesthesia, continuous clinical monitoring of the patient during surgery and the recovery period.     

Anesthetic management of cesarean section in a patient with pulmonary embolism due to protein S deficiency diagnosed postoperatively

A 27-year-old pregnant woman with pulmonary embolism was scheduled for cesarean section. She received anticoagulant therapy with continuous infusion of heparin and prophylactic placement of an inferior vena cava (IVC) filter. Heparin was discontinued 7 hours before operation. Spinal anesthesia using hyperbaric bupivacaine 12 mg was performed and the operation was completed uneventfully. She was given a diagnosis of protein S deficiency after discharge. Preoperative anticoagulant therapy and placement of IVC filter may be effective in preventing new pulmonary embolism.     

Successful therapy of a cardiac arrest during accidental hypothermia using extracorporeal circulation]

We report the case of a 59-year-old woman suffering from profound accidental hypothermia promoted by intoxication with codeine, sedatives, and a beta-blocking agent ingested in a suicidal attempt. Treatment was further complicated by ventricular fibrillation and asystole that was refractory to therapeutic interventions. The comatose patient (Glasgow score 3) was found outdoors in rainy weather--environmental temperature approximately 10 degrees C (50 degrees F)--by children. The skin was rosy when the emergency team arrived. The respiratory rate was low and the ECG showed sinus rhythm with a heart rate of 28/min. No arterial pulsations were detectable, even at the carotid and femoral sites. Because catecholamine therapy failed to increase the heart rate, the patient was suspected to be profoundly hypothermic. After confirming core hypothermia with a rectal temperature of 25 degrees C (77 degrees F) at the initial receiving hospital, transfer to an institution with cardiac surgery facilities was initiated. During this transport and after arrival, ventricular fibrillation occurred at decreasing intervals followed by asystole, which was refractory to large doses of epinephrine. The patient was transferred to the operating room under continuous resuscitation maneuvers and cardiopulmonary bypass was instituted via the femoral vessels. After 110 min of extracorporeal circulation (ECC, flow 4.5 l/min) normothermia was achieved and the asystole reverted spontaneously to sinus rhythm. The patient's course was subsequently complicated by worsening pulmonary gas exchange with signs of pulmonary edema on X-ray films and cardiac failure, which was treated successfully with epinephrine and dopamine. No neurological deficits were detectable after consciousness had returned.(ABSTRACT TRUNCATED AT 250 WORDS)