Der Anaesthesist
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We present a potentially fatal case of acute methaqualone (M) poisoning with very low serum concentrations of M but extremely high levels of its metabolite, 2-methyl-3-(2-hydroxymethyl-phenyl)-4 (3H)-chinazoline (Met-1). A 23-year-old man was admitted to the intensive care unit 2 days after ingestion of 4-5 g M in an suicidal attempt. On admission he was somnolent and poorly responsive to painful stimuli. Physical examination revealed a heart rate of 95 bpm, a blood pressure of 125/65 mmHg, and a normal body temperature. His chest was clear to auscultation, respirations were shallow, and the skin was cyanotic. The electrocardiogram was unremarkable. The chest radiograph showed a normal heart size without pulmonary infiltrates or venous congestion. The pupils were dilated but reactive to light. The neurologic examination was further remarkable for increased limb reflexes, myoclonia, and positive pyramidal signs. During the next 2 days the patient became comatose and developed respiratory insufficiency due to non-cardiogenic pulmonary oedema, which was confirmed by chest radiograph and haemodynamic investigations by means of right heart catheterisation. He required mechanical ventilation for 6 days. Finally, he recovered completely and was discharged in good condition. ⋯ The presented case is the first report of a life-threatening intoxication after M ingestion primarily caused by Met-1. It supports the significance of this metabolite for the toxic effects of the drug. A toxicological screening test based on ELISA proved helpful due to its cross-reactivity with metabolites. In cases similar to ours, resin haemoperfusion may be indicated to remove the metabolites despite low detectable concentrations of the parent substance in the serum.
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Neoplastic or traumatic lesions of the brain stem or the upper spinal cord frequently cause respiratory insufficiency necessitating permanent mechanical ventilation. If the integrity of the diaphragm and its nerves is not affected, adequate ventilation can be achieved by electric stimulation of the phrenic nerves. Diaphragm pacing systems mean the patients can be independent of ventilator treatment. ⋯ The duration of stimulation was increased stepwise from 1 h a day to full-time stimulation. Three weeks after implantation of the diaphragm pacer system the patient could be totally weaned from mechanical ventilation. After a further 2 weeks it was possible to discharge him from the intensive care unit, and he was then transferred to a rehabilitation centre.
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Clinical Trial
[Quantification of variations in arm perfusion after plexus anesthesia with color doppler sonography].
The axillary brachial plexus block is a well-known technique for intra- and postoperative analgesia and sympathetic blockade in hand and microsurgery. The aim of this study was to show the influence of the axillary brachial plexus block on the blood flow as a side effect. METHODS. ⋯ CONCLUSIONS. The brachial plexus block combines two advantages: pain relief and pain management plus temporary sympathectomy. In conclusion, it prevents vasospasms and improves the circulation of the hand in patients undergoing reimplantation of limbs and those with nutritional disorders.
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A separation of the individual latex layers is a known complication of endotracheal armoured tubes manufactured by immersion technique. This can result in herniation into the lumen with obstruction of the tube. Diffusion of nitrous oxide into the inner hernia considerably intensifies the obstruction. ⋯ A too-high drying temperature can cause premature layer separation. The tubes should never be processed more than 80 times. Routine examination of the tubes is imperative, especially at the predilection sites for layer separation.
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Case Reports
[Life-threatening postoperative angioedema following treatment with an angiotensin converting enzyme inhibitor].
Angio-oedema is a recognised complication of angiotensin converting enzyme (ACE) inhibitor therapy, occurring in 0.1% to 0.5% of patients taking captopril, enalapril, or lisinopril. This is the first report of severe angio-oedema complicating therapy with quinapril, a new, long-acting drug. CASE REPORT. ⋯ Despite a significant increase in angio-oedema associated with the use of long-acting ACE-inhibitors, there appears to be a lack of familiarity among anaesthesiologist and other emergency physicians concerning this adverse effect. Withdrawal of the drug is the only effective treatment. High-dose steroids may be helpful, but if there is beginning dyspnoea or stridor, early endoscopically controlled intubation or emergency tracheostomy is essential to avoid hypoxaemia and death, as has occurred in the past.