In the current era of rapid culprit vessel revascularization in acute myocardial infarction, ventricular free wall rupture is becoming increasingly uncommon. In rare cases adherent pericardium may contain this rupture, creating a temporary stable pseudoaneurysm. With the aid of intraoperative pictures, we describe herein a left thoracotomy approach for the surgical correction of a left ventricular pseudoaneurysm secondary to free wall rupture.
Purpose: Methadone is a long acting opioid that is often used effectively to treat cancer pain. Like all opioids, it has risks and side effects. This is a case report of a patient with metastatic rectal cancer who was on large doses of methadone and had a seizure. Clinical Features: A middle-aged woman with stage IV metastatic rectal cancer (diaphragm, liver, lungs) was admitted directly to the hospital from her oncologist's office secondary to uncontrolled pain. The patient was not a candidate for any additional surgery nor radiation/chemotherapy. Her home regimen of methadone 60 mg po tid and methadone 30 mg po q 3hours prn was ineffective in controlling her pain. Over a 3 day hospitalization, the primary service increased her methadone to 90 mg po tid and methadone 90 mg po q 2 hours prn. She was usually maximizing her prn methadone, yielding a daily po methadone intake close to 1300 mg per day. On hospital day #4 the patient was discharged to home on this regimen. The following day she lost consciousness for several minutes and appeared to have a seizure. She went to her local ER where a seizure secondary to methadone was suspected. The patient saw her oncologist 2 days later and was seen in the pain clinic the same day. She was placed on the fentanyl patch 100 mcg/hr, oxycodone 10 mg qid, and ibuprofen 800 mg q 6 hours prn. The methadone was reduced to 60 mg po bid. During a phone follow-up one week later the patient reported her pain was well controlled on this regimen and denied any additional seizures. Future placement of a tunneled epidural catheter was discussed, but deferred secondary to adequate pain relief. The patient died 6 weeks after her initial pain clinic visit. The patient did consent to this being submitted as a case report. Conclusion: Seizure is a known side effect of methadone therapy. This case report describes a seizure that occurred in a cancer patient that was on large dose methadone therapy that had been rapidly increased. It also demonstrates the benefits of opioid rotation and multimodal therapy for patients with cancer pain.
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