Association of acute onset hypertension and tachycardia following intracisternal papaverine administration during intracranial aneurysm surgery: a case report and review of the literature

Subarachnoid hemorrhage is associated with a number of cerebral insults as a result of cerebral vasospasm. Various pharmacological and non-pharmacological techniques are used for relief of cerebral vasospasm. Papaverine, either intraarterially or intracisternally, is advocated for management of vasospasm; however, its use is associated with a number of complications. The case of a patient with an anterior communicating artery aneurysm, who received intracisternal papaverine by instillation after aneurysm clipping, is reported. It was associated with hypertension and tachycardia that was not responsive to usual treatment.     

Severe bradycardia and hypotension after connecting negative pressure to the subgaleal drain during craniotomy closure

Negative pressure drainage systems are often used after craniotomyfor evacuation of potential bleeding. There are several reportsof haemodynamic disturbances with epidural negative pressuredrainage, but such reports are very few for subgaleal drainsplaced over the bone flap. We report a case in which a patientdeveloped severe cardiovascular disturbances after the vacuumdrainage was connected to a subgaleal drain after craniotomyfor aneurysm clipping. The patient had no significant cardiachistory, had an uneventful intra-operative course and yet developedbradycardia and hypotension, which were reproducible and severeenough to require atropine administration. Anaesthetists mustbe aware of these effects, so that they can anticipate and treatsuch complications.     

Clinical prospective study of biochemical markers and evoked potentials for identifying adverse neurological outcome after thoracic and thoracoabdominal aortic aneurysm surgery

Background. Neurological deficit after repair of a thoracicor thoracoabdominal aortic aneurysm (TAA/TAAA) remains a devastatingcomplication. The aim of our study was to investigate the clinicalvalue of biochemical markers [S-100B, neurone-specific enolase(NSE) and lactate dehydrogenase (LD)], evoked potentials andtheir combinations for identifying adverse neurological outcomeafter TAA/TAAA surgery. Methods. From 69 patients, cerebrospinal fluid and blood samplesfor biochemical analysis were drawn after the induction of anaesthesia,during the cross-clamp period, 5 min, 2, 4, 6, 8, and 19 h,respectively, after reperfusion. In addition, continuous perioperativerecording of motor-evoked potentials after transcranial electricalstimulation (tcMEP) and somatosensory-evoked potentials wascarried out. Furthermore, neurological examinations were performed. Results. In patients with a defined decrease in lower extremitytcMEP during the cross-clamp period, we found that combinationsof the serum concentrations of S-100B and tcMEP ratios at 4,6, and 8 h after reperfusion had a positive and negative predictivevalue of 100% in predicting adverse neurological outcome afterTAA/TAAA surgery. Furthermore, combinations of the serum concentrationsof S-100B and NSE or LD at 19 h after reperfusion had both apositive and negative predictive value of 100% in identifyingpatients with adverse outcome after TAA/TAAA repair. Conclusions. TcMEP monitoring during TAA/TAAA surgery seemsto be an effective but not completely sufficient guide in ourprotective multi-modality strategy. Combinations of the serumconcentrations of S-100B and tcMEP ratios during the early reperfusionperiod might be associated with adverse neurological complications.Furthermore, biochemical markers could detect central nervoussystem injury on the first postoperative day and may have prognosticvalue.     

Perioperative management of blood glucose during open heart surgery in infants and children

The perioperative management of blood glucose has been controversial since clinical associations between hyperglycemia and adverse outcomes were first reported more than two decades ago. Despite some early evidence supporting a causal relationship between hyperglycemia and adverse outcomes, prospective trials of tight glycemic control have been inconclusive, except in selected populations, like adult diabetics. These trials have consistently reported dramatic increases in the incidence and severity of hypoglycemia, which may also have associated adverse outcomes. Bedside glucose monitors typically used to manage glucose have increasingly been found to introduce systematic inaccuracies. Relevant studies of infants and children undergoing cardiac surgery are considerably fewer in number, requiring clinicians to extrapolate from other clinical conditions and patient populations.     

PaO2 during anaesthesia and years of smoking predict late postoperative hypoxaemia and complications after upper abdominal surgery in patients without preoperative cardiopulmonary dysfunction

Background: The incidence of late postoperative hypoxaemia and complications after upper abdominal surgery is 20–50% among cardiopulmonary healthy patients. Atelectasis development during anaesthesia and surgery is the main hypothesis to explain postoperative hypoxaemia. This study tested the predictive value of PaO₂<19 kPa during combined general and thoracic epidural anaesthesia and the preoperative functional residual capacity (FRC) reduction in the 30° head tilt‐down position for the development of late prolonged postoperative hypoxaemia, PaO₂<8.5 kPa for a minimum of 3 out of 4 days, and other complications. Methods: Forty patients without cardiopulmonary morbidity, assessed by ECG, spirometry, FRC and diffusion capacity preoperatively, underwent upper abdominal surgery. PaO₂ during anaesthesia and preoperative FRC reduction were compared to known risk factors for the development of hypoxaemia and complications: age, pack‐years of smoking and duration of operation. The effect of optimizing pulmonary compliance with peroperative positive end‐expiratory pressure (PEEP) on postoperative hypoxaemia and complications was evaluated in a blinded and randomized manner. Results: Late prolonged postoperative hypoxaemia and other complications were found in 37% and 38% of the patients, respectively. Patients with PaO₂>19 kPa during anaesthesia with F_IO₂=0.33 exhibited a risk, irrespective of PEEP status, of suffering late prolonged hypoxaemia of 0% (0;23) and patients with PaO₂<19 kPa a risk of 52% (32;71), P<0.005. Having smoked more than 20 pack‐years was associated with a 47% (19;75) higher incidence of postoperative complications than having smoked less than 20 pack‐years, P<0.006. Conclusions: PaO₂ during anaesthesia and smoked pack‐years provide new tools evaluating patients undergoing upper abdominal surgery in order to predict the patients who develop late postoperative hypoxaemia and complications.