Acute left ventricular dysfunction due to Tako-tsubo syndrome after induction of general anesthesia

Tako-tsubo cardiomyopathy is a recently described form of transient ventricular dysfunction that is not associated with coronary vessels obstruction, although its clinical manifestations are often similar to those of myocardial ischemia. This syndrome is possibly due to an excess of catecholamines, and it is associated with emotional and physical stress and surgery. However, the pathophysiological relation to anaesthesia has not yet been clarified. We report a case of Tako-tsubo cardiomyopathy that ensued immediately after induction of general anaesthesia for elective surgery in a patient submitted to laparoscopic cholecystectomy. The patient was first treated as if affected by myocardial ischemia, but a rapidly performed emergency coronary angiography showed normal epicardial coronary vessels with a significant reduction of left ventricular function. The coronary angiography ruled out the diagnosis of typical myocardial ischemia and allowed for the arrival at the correct diagnosis. The transient ventricular ballooning was attributed to the recently described Tako-tsubo syndrome. Prompt treatment allowed control of symptoms, and the patient was safely treated and discharged on day 15. Although it is difficult to identify the cause of this syndrome, it may be argued that, during general anaesthesia and particularly at induction, the imperfect control of catecholamine excess may induce cardiac damage in predisposed subjects.     

Myocardial infarction after general anesthesia

During 1967 and 1968, a total of 32,877 patients had general anesthesia at the Mayo Clinic; 422 had previous myocardial infarction. Of these 6.6% experienced another infarction during the first postoperative week. There was no relationship between incidence of postoperative reinfarction and type or duration of anesthesia. However, operations on the thorax and upper abdomen were followed by three times as many reinfarctions as operations at other sites. Patients who were operated on within three months of infarction had a 37% reinfarction rate. This rate decreased to 16% in patients at three to six months after infarction, and remained at 4% to 5% when infarction had occurred more than six months previously. A significantly higher number of myocardial infarctions occurred during the third postoperative day.     

Epiglottic hematoma leading to airway obstruction after general anesthesia

Bleeding into the upper airway can cause airway obstruction and death if not recognized promptly. Anesthesiologists are quite familiar with potential airway obstruction from acute epiglottitis, but they may be less familiar with the potential for airway obstruction from epiglottic hematoma. We report what we believe is the second case of epiglottic hematoma after anesthesia and surgery that led to an acute upper airway obstruction. Our case was unique in that there was no excessive airway trauma during tracheal intubation. Most important, this case emphasizes that patients receiving multiple anticoagulants--as our patient was--are at risk for airway bleeding, epiglottic hematoma formation, and airway obstruction.     

Modafinil improves recovery after general anesthesia

Recovery from general anesthesia often involves residual sedation, drowsiness, fatigue, and lack of energy that may last hours to days. Modafinil is a wakefulness-promoting drug approved for patients with excessive daytime sleepiness associated with narcolepsy. We evaluated the effect of single doses of modafinil (200 mg) and placebo in patients recovering from general anesthesia. Thirty-four subjects participated in this prospective, randomized, double-blind study approved by our IRB. Preoperatively, patients were asked to rate various symptoms they had experienced over the previous 24-h using a verbal analog scale (VAS) of 0 to 10 as well as discrete scale when indicated. Postoperatively, once the patient was able to tolerate oral intake and met our institutional discharge criteria, the study drug (modafinil 200 mg or placebo) was administered with a sip of water. Patients were contacted 24 (1) hours after dosing to evaluate postdischarge symptoms. Patients in the placebo group reported significantly more postoperative fatigue (4.8 [3.3] versus 1.4 [1.8]), exhaustion (4.3 [3.3] versus 2.4 [3.1]), or degree of feeling worn out (4.7 [3.6] versus 2.9 [2.4]). Significantly more patients reported moderate to severe fatigue in the placebo group (65% versus 12%). Two major themes of "alertness" and "energy" were expressed by 71% of the patients receiving modafinil versus 18% of those receiving placebo. Patients recovering from general anesthesia can significantly benefit from modafinil. IMPLICATIONS: Modafinil significantly reduces fatigue and improves feelings of alertness and energy in postoperative patients. Patients recovering from general anesthesia can significantly benefit from modafinil administration.     

全身麻醉恢复期并发癔症

癔症性昏迷属假性昏迷范畴,在麻醉恢复期发作较少见,而恢复期昏迷属麻醉急症与意外,故两者的鉴别显得非常重要.报道1例全麻苏醒后突发昏迷患者,被诊断为假性昏迷——癔症性昏迷.麻醉医师应具备识别各类昏迷的能力,当昏迷发生后迅速启动鉴别诊断程序,早期诊断与治疗对麻醉意外事件转归、缓和紧张医患关系都具有重要意义.     

Hypoxemia after general anesthesia in children

Postoperative hypoxemia has been well documented in adults but not in infants and children, although they are potentially more susceptible to airway closure and to disturbances in pulmonary gas exchange. In a prospective study, we measured arterial oxygen saturation (SaO2) with a pulse oximeter in 97 ASA class I infants and children breathing room air before and after general anesthesia for superficial surgical procedures. Mean preoperative SaO2 was 97.6 +/- 0.15% (SEM). On arrival in the recovery room after anesthesia mean SaO2 in room air had decreased significantly (P less than 0.01) to 93.0 +/- 0.49% (range 100-71%), corresponding to calculated arterial oxygen tension (PaO2) of about 66 mm Hg. The second reading, 5-15 min later, also showed a statistically significant (P less than 0.01) decrease in SaO2 (94.1 +/- 0.35%). There was no statistical difference in SaO2 between patients who received inhalation anesthesia alone and those who were given narcotics. There was also no correlation between postoperative reduction in SaO2 and duration of anesthesia or patient age. Of 67 patients who were asleep on arrival in the recovery room, 47 who remained asleep at the second SaO2 reading had an average increase in SaO2 of less than 1%. In contrast, in those patients who awoke, average SaO2 increased more than 4% during a similar time period--a difference that was statistically significant (P less than 0.02).     

Transient global amnesia after general anesthesia

Transient global amnesia (TGA) is an amnestic syndrome, clinically dramatic but benign in nature. The hallmark of TGA is brief inability to form new memories and recall past memories despite otherwise normal neurological function. In a significant number of patients with TGA a stressful precipitating factor can be identified. We report two cases of TGA after uneventful general anesthesia. Anesthesia per se does not appear to be a direct trigger of TGA, as our first patient had a second anesthetic the next day without recurrence of TGA. Because the presentation of TGA can be dramatic and may mimic an acute cerebral ischemic event, a thorough neurologic evaluation should be pursued.     

Age-related cognitive recovery after general anesthesia

This study was designed to quantify the rate of mental recovery in elderly and young patients after general anesthesia for intraabdominal surgery (cholecystectomy). Forty patients (25-83 yr) were given four tests assessing neuropsychological function once preoperatively and on five occasions postoperatively. Two of the four neuropsychological tests showed impairment in scores in the elderly patients on the first postoperative day (Symbol Digit Modalities Test, P less than 0.004; The Trail Making Test, P less than 0.03). In addition, one of the tests (Symbol Digit Modalities Test) showed a deterioration in the younger patients (P less than 0.05). The changes that did occur in these tests on the first postoperative day reverted to baseline levels thereafter. There were no significant changes in the remaining two tests, the Mini Mental State Test or the Digit Span Test, at any time in either group. We conclude that postoperative mental deterioration is no greater in elderly than in young patients.     

Cervical spondylosis revealed after general anesthesia

We present a case of complicated postoperative nerve injury. A 70-year-old man complained of partial paralysis and numbness of the left forearm 1.5 hour after operation for femoral artery bypass graft. Postoperative cervical spine MRI revealed cervical spondylotic radiculopathy. The MRI findings could account for his symptom. Not only peripheral nerve injury but the cervical radiculopathy may play an important role in perioperative neuropathy.