Der Anaesthesist
-
Randomized Controlled Trial Clinical Trial
[Thromboembolism prevention with low dose heparin and spinal anesthesia--a risky combination?].
Spinal or intracranial haematoma is a rare but severe complication of spinal/epidural anaesthesia with an incidence of less than 1:100,000. Coagulation defects, traumatic puncture, and anticoagulant drugs are assumed to be risk factors for the development of this kind of haematoma. Whether the risk of bleeding after spinal/epidural anaesthesia is increased by the administration of low-dose heparin (unfractionated or fractionated) for thromboprophylaxis is currently under discussion. ⋯ We suggest that the development of spinal or intracranial haematoma after spinal/epidural anaesthesia is a multifactorial event. An influence of low-dose heparin prophylaxis as a cofactor cannot wholly be excluded because of the difficulty of studying the problem in a prospective way. The few case reports have to be seen in the context of millions of patients who have received either unfractionated or LMW heparin and lumbar or thoracic regional anaesthesia without any complication. We conclude that low-dose heparin prophylaxis (fractionated or unfractionated) is not a definite contraindication to spinal/epidural anaesthesia. High-risk (ASA III/IV) patients in particular benefit from effective postoperative analgesia achieved by local anaesthetics in combination with effective heparin thromboprophylaxis. Nevertheless, the absolute contraindications for regional anaesthesia must be respected and an individual risk/benefit analysis should be performed for every patient. An adequate time interval between application of heparin and regional anaesthesia or removal of a spinal/epidural catheter, atraumatic puncture technique, and careful neurologic monitoring during the post-operative period can minimise the risk of complications.
-
Randomized Controlled Trial Comparative Study Clinical Trial
[Intravenous sedation of spontaneously breathing infants and small children before magnetic resonance tomography. A comparison of propofol and methohexital].
The purpose of the present study was to compare two sedation regimens with either propofol (P) or methohexital (M) for elective magnetic resonance imaging (MRI) in children with respect to safety, side effects, recovery, and discharge time. ⋯ Intravenous sedation with M or P using the reported technique is a safe regimen for children undergoing elective MRI. The fast recovery and discharge times seem to offer advantages over general anaesthesia with endotracheal intubation. The faster recovery and discharge of only a few minutes after P compared with M is without clinical relevance.
-
Human recombinant interleukin 2 (IL-2), alone or in combination with other cytokines, is currently under investigation for the immunotherapy of metastatic tumours. Objective responses of 20-35% have been reported in patients with disseminated melanoma and renal cell carcinoma who received high-dose intravenous IL-2 in combination with interferon-alpha (IFN alpha). However, treatment with IL-2 is complicated by a syndrome of life-threatening adverse reactions such as disseminated vascular leakage, fluid retention, severe hypotension, and (reversible) multiple organ dysfunction (MODS). A systemic inflammatory reaction (SIRS/sepsis sepsis-like haemodynamic pattern has been described in patients after IL-2 bolus application alone. Our purpose was to study the haemodynamic changes in patients treated with high-dose IL-2 administered as a constant infusion and in combination with IFN alpha. ⋯ After their daily i.m. injections of IFN alpha, patients had short episodes of fever and tachycardia without significant drops in BP. A few hours after transfer to the ICU and continuous infusion of IL-2, they developed a syndrome of fever, tachycardia and tachypnoea. The haemodynamic values after 5 days of IFN alpha therapy remained in the normal range, whereas those during IL-2 infusion strongly resembled SIRS and sepsis, with a decrease in MAP (98 to 28 mm Hg) and systemic vascular resistance (SVR, 1477 to 805 dyn.s.cm-5) and an increase in cardiac output (cardiac index 2.8 to 4.3 l.min-1.m-2). MAP often had to be stablilized with colloids during the last 48 h of therapy; 5 patients had nadir values below 60 mm Hg, or 30% below basic values in hypertensive patients. Catecholamine therapy became mandatory in 1 patient and therapy had to be discontinued. Surprisingly, some patients already had elevated plasma lactate concentrations after IFN alpha therapy. During IL-2 infusion mean plasma lactate levels increased from 2.3 to 3.2 mmol.l-1 and all patients had lactate concentrations above 2.0 mmol.l-1 at the end of therapy. During the last 48 to 72 h of IL-2 infusion, patients suffered from MODS with altered mental state (7 patients), oliogoanuria (all patients), cardiac dysrhythmias (4 patients), congestive heart failure (1 patient, which led to a second case of therapy interruption), elevated bilirubin (4 patients), and pulmonary dysfunction. In 9 patients supplementary oxygen was necessary when psaO2 fell below 92
-
Case Reports
[Neurologic complications following total endoprothesis implantation of the hip under peridural catheter anesthesia].
This case report describes paralysis of the plantar flexors and extensors after a total hip replacement in a 33-year-old woman performed under epidural anaesthesia (PDA). Six years previously, the patient had undergone a bone marrow transplantation for chronic myeloid leukaemia. She had developed a deep vein thrombosis, a pulmonary embolus, and a severe graft-versus-host reaction of the skin, leading to markedly reduced mouth opening. ⋯ It remains uncertain whether the PDA in a patient receiving low-molecular-weight heparin resulting in a the suspected epidural haematoma was the cause of the neurological sequelae and in agreement with the consultant neurologist, we believe that a direct traumatic lesion of the L5/S1 segment or damage to the sciatic nerve are also likely causes of the symptoms. Undoubtedly, the lack of adequate postoperative neurological monitoring and the intraoperative administration of dextran despite the known epidural vascular lesion deserve criticism. This case report demonstrates the often complex development of neurological complications after nerve blocks, where a definite cause can frequently not be determined.