Laparoskopische Cholezystektomie bei einer Patientin mit unilateraler Wabenlunge

Laparoskopische Operationsmethoden sind aufgrund der postoperativen Vorteile für den Patienten (weniger pulmonale Komplikationen, schnellere Erholung und Mobilisation bei geringeren Schmerzen) zunehmend an die Stelle der offenen Verfahren getreten. Vereinzelt besteht noch Unsicherheit, ob diese Operationsmethode wegen der spezifischen intraoperativen Effekte des Pneumoperitoneums auf Herzkreislauf- und Lungenfunktion auch für kardiale oder pulmonale Hochrisikopatienten geeignet ist. Wir schildern das an?sthesiologische Vorgehen für eine laparoskopische Cholezystektomie bei einer 72-j?hrigen Patientin mit angeborener linksseitiger Wabenlunge (2 riesige Zysten). Die Vitalkapazit?t war auf 1 Liter (45%), die forcierte exspiratorische Einsekundenkapazit?t (FEV1) auf 41% reduziert. Die Patientin wurde spontanatmend fiberoptisch mit einem Doppellumentubus intubiert und die rechte Lunge von Hand ventiliert; die linke Lunge wurde apnoisch oxygeniert. Der intraabdominelle Druck w?hrend des Pneumoperitoneums wurde auf 10 mmHg begrenzt. H?modynamische und ventilatorische Parameter wurden invasiv engmaschig überwacht. Die pulsoxymetrische Sauerstoffs?ttigung betrug jederzeit >95%, eine intraoperative Hyperkapnie (paCO₂ 57 mmHg) wurde toleriert. Der intra- und der postoperative Verlauf waren komplikationslos. Gerade pulmonale Risikopatienten profitieren von laparoskopischen Operationsmethoden wegen der geringeren postoperativen Beeintr?chtigung der Lungenfunktion. Aufgrund der pathophysiologischen Ver?nderungen unter Pneumoperitoneum ist für solche Patienten intraoperativ ein erweitertes Monitoring und ein angepasstes an?sthesiologisches Management notwendig.     

Laparoskopische Cholezystektomie bei einer Patientin mit unilateraler Wabenlunge

Laparoscopic surgery of the gallbladder has increasingly replaced open techniques due to postoperative benefits (less pulmonary complications, less postoperative pain, earlier mobilisation). Specific intraoperative effects of pneumoperitoneum have led to some uncertainty if cardiac and/or pulmonary high-risk cases should be done laparoscopically. We describe anaesthesiological management of a 72 year old patient with a unilateral leftsided honeycomb lung (two very large cysts) to undergo laparoscopic cholecystectomy. Vital capacity was reduced to 45%, forced expiratory 1 second volume to 41%, preoperative bloodgas analysis revealed a paO2 of 64 mmHg and a paCO2 of 40 mmHg. Under spontaneous breathing the patient was fiberoptically intubated with a left sided double lumen tube (Mallinckrodt, Athlone/Irland; 37 Ch) using balanced anaesthesia. The healthy right lung was hand ventilated with 100% oxygen to avoid excessive airway pressures (peak airway pressure 27 mbar, mean airway pressure 22-24 mbar). The diseased left lung was passively insufflated with oxygen. The intraabdominal pressure was limited to 10 mmHg. Muscle relaxation was achieved with atracurium under monitoring using a nerve stimulator. The paCO2 increased from 40 to 57 mmHg during the operation, but returned to normal immediately postoperatively. All other ventilatory and hemodynamic parameters were uneventful during the 35 minute procedure. The patient was extubated at the end of the procedure and monitored on the intensive care ward for one night. A postoperative chest X-ray revealed a mediastinal shift of 2 cm to the right, healthy side as well as an atelectasis on this side. The shift was most likely due to hypoventilation of the right lung, with the ensuing atelectasis drawing the mediastinum to the right. Under physiotherapy this shift had resolved by the next morning. The patient could be discharged from hospital on day seven and fully recovered. Especially the severely cardiopulmonary compromised patient benefits from a laparoscopic procedure, due to less postoperative reduction of pulmonary function. Careful and individually adapted monitoring and anaesthetic techniques are necessary to successfully counteract the special implications of pnemoperitoneum.     

Posttraumatische Rotationsfehlstellung des Femurs bei einer Patientin mit Paraplegie

A 37-year old woman with paraplegia sustained a posttraumatic rotational deformity of the femur of 40 degrees after the osteosynthesis of a femur fracture. In the consequence she got several problems in her everyday life, such as problems in handling the wheel-chair and in catheterism. The determination of anteversion of the femoral neck by computed tomography is necessary for quantifying rotational faults and planning of corrective osteotomy. Our patient recuperated as the same level of independence after a subtrochanteric corrective osteotomy as before the fracture of the femur.     

Harnstauungsnieren beidseits infolge opiatinduzierter Darmspastik bei einer Patientin mit Ileumconduit

A 47-year-old woman with spina bifida and an ileal conduit since childhood presented with left-sided flank pain, bilateral hydronephrosis and oliguria suspicious for a recurrent stenosis at the ureteral implantation site. Her history revealed a recent increase in her pain medication with opioids for treatment of neuropathic pain. After insertion of percutaneous nephrostomy on the left side and confirmation of the stenosis, open reimplantation of the ureter was already discussed with the patient. However after dose reduction of the opioid therapy hydronephrosis resolved. Thus opioid-induced bowel spasm was probably the cause for the obstruction.     

Cumarinnekrose bei einer jungen Patientin

Coumarin-induced necrosis is a rare but severe complication of therapy with coumarin or its derivatives. The pathophysiology is still not well known. A case of a very young female patient who suffered from Marcumar-induced necrosis with loss of a forefoot is described. The differential diagnosis includes among others phlegmasia cerulea dolens.     

Einsatz der prähospitalen Lyse bei einer Patientin mit Vorderwandinfarkt und pulsloser ventrikulärer Tachykardie

This case report describes an 83-year-old patient with a known history of coronary heart disease suffering acute chest pain. The on-site emergency physician diagnosed acute anterior myocardial infarction and during the further course was confronted with pulseless ventricular tachycardia. After returning the heart’s normal rhythm by defibrillation, prehospital thrombolysis was performed to further stabilize the patient. This procedure makes transfer to the receiving hospital possible where further treatment can then be instituted. One-third of all patients suffering a heart attack die before ever reaching a clinic. Implementation of rules conforming to European and German guidelines on management of STEMI involves performance of percutaneous transluminal coronary angioplasty (PTCA) as the recommended standard. There must be strategies available to the attending emergency physician for on-site stabilization of those patients manifesting additional cardiac complications. Prehospital systemic thrombolysis represents a sensible measure for these cases.     

Dysphagie mit unklarer Ursache bei 20-jähriger Patientin

Many different causes have been described for dysphagia. An uncommon one is trichobezoars, which are mainly caused by trichotillomania. This may lead to mechanical obstruction and peritonitis due to perforation of the gut. Here we report a case of a giant trichobezoar (30×20×10 cm) in the stomach of a 20-year-old female. The patient presented unclear dysphagia and a palpable tumor in the epigastrium. Computed tomography showed an inhomogeneous tumor spreading from the upper belly to the pelvis. A B1 resection was performed and the patient recovered uneventfully.     

Fulminante Candida-Sepsis bei einer 28-jährigen Patientin mit Erstdiagnose eines Diabetes mellitus und ausgeprägtem hyperosmolarem Koma

Die Anaesthesiologie - Berichtet wird über eine 28-jährige bis dato nicht bekannt vorerkrankte Patientin, welche mit dem Rettungsdienst in komatösem Zustand auf unsere...     

Traumaversorgung einer schwerstverletzten schwangeren Patientin

Background

Trauma management of pregnant patients is a particularly challenging task for the emergency room team.

Case report

This article reports the case of a 36-year-old patient in the last trimester of pregnancy after an epilepsy-related fall from a great height. The necessary diagnostic and therapeutic procedures concerning the mother should not be avoided due to an assumed protection of the fetus. Any delay in these procedures can endanger the lives of both the mother and the unborn child.     

Postoperativ aufgetretene reversible posteriore Enzephalopathie bei einem Patientin mit Morbus Crohn

Posterior encephalopathy (PE) is a rare condition with different origins and unknown pathogenesis. We report on a case of a 16-year-old boy with Crohn's disease who developed PE after peridural anesthesia with ropivacain. A possible connection between PE, ropivacain and Crohn's disease is discussed on the basis of the current literature.     

56-jährige Patientin mit pathologischer subkapitaler Humerusfraktur bei Morbus Gaucher

We present a case of a pathologic humerus fracture in a patient with the initial diagnosis of Gaucher’s disease, which is the most frequent form of lipidosis transmitted as an autosomal recessive trait. It often results in orthopaedic complications with pain, osteonecrosis, fractures and joint infractions. If there is cause for suspicion, β-glucocerebrosidase in white blood cells should be measured because of the important consequences for treatment. Therapy with a modified enzyme is effective in managing the disease.     

Stenosierende Magensyphilis bei einer Jugendlichen mit kongenitaler Lues

Zusammenfassung Es wird ein Fall von Magensyphilis bei kongenitaler Lues bei einem 15j. M?dchen beschrieben. Der Krankheitsbeginn liegt über 2 Jahre zurück, damals wurde r?ntgenologisch ein Ulcus ventriculi festgestellt. Unter antiluischer Behandlung kam es zu einer Schrumpfung im unteren Corpusteil des Magens, die zu einer hochgradigen Stenose führte, diese machte operative Entfernung des erkrankten Magenteiles nachBillroth II erforderlich. Alle mitgeteilten Befunde sprechen für die Diagnose Magenlues, und zwar dürfte ein „Gumma mit seinen Folgen“ (Gruppe 2 der Einteilung nachKalk) bestanden haben. Es handelt sich unseres Wissens um den 7. Fall der Weltliteratur. Die Seltenheit der Erkrankung gab uns Veranlassung, das Krankheitsbild mitzuteilen.     

Anästhesiologische Aspekte der Schwangerschaft und Entbindung bei einer Patientin nach modifizierter Fontan-Operation

The number of patients with congenital cyanotic heart disease who reach child-bearing age is increasing. This is partly a consquence of the high long-term survival and the haemodynamic benefits resulting from the Fontan procedure, which is used for the definitive palliation of such cyanotic heart disease as tricuspid atresia and single ventricle. However, so far little experience has been recorded with pregnant patients who have undergone right ventricular exclusion procedures. The particular physiology of a univentricular heart and a passive, non-pulsatile blood flow through the lungs has significant implications for the anaesthetic obstetric management of these patients. We report a case of successful pregnancy and caesarean delivery after a modified Fontan procedure. Case report. The patient was a 30-year-old pregnant woman with a singleton pregnancy. At the age of 20, after four palliative shunt operations, she had undergone a modified Fontan operation due to tricuspid atresia with a single ventricle, d-transposition of the great arteries, pulmonary atresia and a single atrium. Following the Fontan repair, she initially suffered from intermittent Wolff-Parkinson-White syndrome and isorhythmic AV dissociation. The pregnancy was uneventful, and caesarean section was scheduled for 32 weeks' gestation. Because of the increased risk of thrombosis, the patient was treated with s.c. heparin preoperatively; for this reason, epidural anaesthesia was excluded, though it may otherwise be preferred for such patients. Amoxicilline was used to prevent endocarditis. At the date of caesarean delivery her body weight was 54?kg and boy height, 155?cm. Before induction of anaesthesia, a central venous and a radial artery catheter were placed for invasive pressure monitoring. An exaggerated left lateral tilt position was used to avoid aortocaval compression. After careful preoxygenation, anaesthesia was induced with 24?mg etomidate, 1.5?mg norcuronium, and 75?mg succinylcholine. Halothane 0.5–0.7% in oxygen was used during the first few minutes of surgery. Central venous pressure under mechanical ventilation was 20?mmHg, while the heart rate varied between 70 and 90?bpm. Delivery was accomplished 8?min after the induction of anaesthesia. The Apgar scores after 1 and 5?min were 9 and 10, respectively. Anaesthesia was continued with fentanyl, midazolam and nitrous oxide 50%. The remainder of surgery was unevenful. The child is now 5 years old and healthy. The mother has a near-normal activity level and does not need any help to care for her child. Discussion. After a modified Fontan repair, i.e. atriopulmonary or total cavopulmonary anastomosis, the pulsatile pulmonary blood flow is converted to a passive, non-pulsatile blood flow that depends critically both on the pressure gradient between right (RAP) and left atrial pressure (LAP) and on pulmonary vascular resistance (PVR). Thus, the maintenance of an adequate transpulmonary pressure gradient and avoidance of an increase in PVR are of major importance for the obstetric anaesthetic management in patients who have undergone right ventricular exclusion procedures. Impairment of venous return caused by slight caval compression or high airway pressure may reduce cardiac output more critically than in patients with a normal circulation. Conclusion. This case demonstrates that the haemodynamic consequences of pregnancy and of caesarean delivery under general anaesthesia can be tolerated in post-Fontan patients despite the absence of a contractile pulmonary ventricle.     

Versorgung einer schwangeren Patientin nach Polytrauma

Multiple trauma during pregnancy is a relatively rare situation which poses a great challenge for the team in charge of treatment. A concomitant disease, such as thrombotic thrombocytopenic purpura (TTP) with thrombocytic coagulopathy increases the complexity of the treatment problems. This article describes the case of a 36-year-old pregnant woman referred to this hospital suffering from multiple trauma with severe liver rupture. Stabilization was achieved after an emergency Caesarean section and packing of the liver. Recurrent massive bleeding from the liver occurred after depacking and was treated successfully with recombinant factor VIIa. The concomitant TTP was treated by transfusion of fresh frozen plasma and corticosteroids. Rapid initiation of therapy was the goal to achieve hemostasis and prevent aggravation of the coagulation disorder and an unfavourable outcome despite severe thrombocytopenia.