Der Anaesthesist
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We report a case of acute embolic obstruction of the aorta in a 36-year-old patient undergoing coronary artery bypass surgery. After declamping of the aorta at the end of extracorporeal circulation, blood pressure measured in the femoral artery dropped to 10-20 mmHg. Neither clinical signs of arterial hypotension nor a dysfunction of the arterial line could be observed. Cannulation of the left radial artery revealed a normal systemic blood pressure. After the end of surgery, pale and pulseless lower extremities were observed, suggesting arterial obstruction. A 6 X 3 cm embolus occluding the aortic bifurcation could be extracted with a Fogarty catheter; its origin was presumably an aneurysmatic area of the left ventricle. Surgical manipulation had mobilised the mural thrombus, which caused Leriche's syndrome after aortic declamping and defibrillation of the heart. ⋯ In case of sudden alterations of lower extremity perfusion, anaesthetists and surgeons should consider the rare complication of acute embolic obstruction of the aorta originating from intracardiac thrombotic material. Routine monitoring with transoesophageal echocardiography should thus be considered in patients at risk for intracardiac thrombus formation.
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Hypnosis can be an alternative to cerebral sedatives with no side effects for sedation during regional anaesthesia, especially in high-risk and fearful patients. Patients who have experience with relating techniques like Jakobson's progressive muscle relaxation are very good candidates for hypnosis. It is contraindicated in patients with psychotic disorders, major depression, and abuse of hallucinogenic drugs. ⋯ Of ten cases, hypnosis was successful in six (vegetative stress symptoms like tachycardia or shivering stopped immediately after induction of hypnosis), not completely successful in two (interruption of hypnosis after 30 min) and unsuccessful in two. Four cases where hypnosis was used during spinal anaesthesia for knee and hip surgery or brachial plexus block for open fixation of Colles' fracture are discussed as examples. As it requires more time (15 to 45 min to inform and test the patient) and special organisational conditions hypnosis will not become a routine procedure, but is still a good alternative for selected cases.
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Randomized Controlled Trial Clinical Trial
[The effects of cimetidine on the pharmacodynamics of rocuronium].
Cimetidine is a commonly used H2-receptor antagonist that has been recommended for the prevention of acid aspiration syndrome and has been shown to potentiate vecuronium-induced neuromuscular block. The present study was designed to investigate the influence of a single IV dose of cimetidine on the neuromuscular effects of rocuronium, an analogue of vecuronium with a short onset time. ⋯ The results of the present study demonstrate that cimetidine does not increase the duration of rocuronium neuromuscular blockade. Inhibition of the cytochrome P450 system or a direct effect at the neuromuscular junction have been suggested as the mechanisms of drug interaction associated with cimetidine. Impairment of hepatic microsomal drug metabolism results in a prolonged duration of action of vecuronium, which appears to be eliminated primarily via the liver. Data on the elimination pathway of rocuronium in humans are not available. The fact that cimetidine does not alter the recovery from rocuronium-induced neuromuscular block confirms a previous suggestion that rocuronium may not be eliminated principally by the liver. A direct effect of cimetidine on the neuromuscular junction could not be confirmed by this study. Therefore, cimetidine can be given as premedication without a risk of prolonged rocuronium block.