We present a case of fatal cardiac tamponade that occurred in association with a peripherally inserted central catheter (PICC) inserted from the right antecubital fossa. Migration of the catheter from the right atrium within 24 h of insertion lead to the administration of a potassium-enriched sodium chloride solution into the pericardial space with the development of ST-segment elevation and progression to pulseless electrical activity and, subsequently, ventricular fibrillation. Although signs of tamponade were seen on echocardiography, we propose that myocardial hyperkalaemia from the diffusion of potassium through the epicardium accounted for some of the clinical picture. PICC lines carry a greater risk of migration because of the tip movement associated with arm abduction and, therefore, care must be taken to ensure that the catheter tip is correctly positioned to reduce this risk. When such catheters are used for intra-operative central venous access, we believe chest radiography is mandatory before fluid administration through the catheter, but that this is unnecessary when the catheter is being used solely for central venous pressure monitoring. The use of softer catheters may reduce the risk of vessel perforation. Once tamponade is suspected, all drugs and infusions administered via the catheter should be reviewed, the catheter aspirated and echocardiography performed urgently. This may be facilitated by the greater availability of limited bedside echocardiography within critical care units and theatre complexes.
This study was designed to evaluate the effect of transfusion guidelines on perioperative blood usage with a view to identifying a protocol for transfusion therapy in our hospital. Eighty consecutive patients with normal haemoglobin concentrations presenting for total hip arthroplasty were studied. The maximum allowable blood loss (MABL) was calculated for each patient using the formula of Kallos et al. Blood loss up to this value was replaced with Haemaccel. When the MABL was reached, a haematocrit (Hct) was performed and blood was given if the Hct was less than 30 in men and 27 in women. Otherwise replacement was with Haemaccel. All postoperative complications, duration of hospital stay, and physiotherapy compliance assessments were recorded. A discharge Hct > 36% was the criterion for overtransfusion. The results were compared with findings from a retrospective group before the introduction of these guidelines. Analysis of the data demonstrated a reduction in the frequency of transfusion (97% vs 32% P < 0.05), the volume transfused (2.7 vs 1.3 units P < 0.05), and the incidence of overtransfusion (45% vs 5% P < 0.05) between the two groups of patients. There was no difference between the groups in complication rate, duration of hospital stay or physiotherapy scoring. We conclude that the introduction of guidelines for transfusion in total hip arthroplasty patients has produced a marked reduction in blood usage in our hospital without detrimental effect.
In a double-blind, randomised controlled trial, we studied 40 patients who received one of four intra-articular injections at the end of arthroscopic surgery. Each group contained ten patients. The patients in Group 1 received normal saline 25 ml; those in Group 2 received bupivacaine 0.25% 25 ml; those in Group 3 received morphine 5 mg in normal saline 25 ml; and those in Group 4 received a combination of bupivacaine 0.5% 12.5 ml and 5 mg of morphine made up to 25 ml with normal saline to produce the same bupivacaine concentration as Group 2. At the time the patient awoke, and 30min, Ihr, Ihr 30min, 2hr, 4hr, 8hr, 12hr, and 24hr postoperatively, pain was assessed using a visual analogue scale. The need for supplementary analgesic agents in the first 24 hours was recorded. All pain scores were significantly lower (P< 0.05) in Groups 2, 3 and 4 compared with the control group with the exception of Group 2 at 24 hours. Pain scores were significantly lower (P<0.05) for Group 2 compared with Group 3 for the first 90 minutes postoperatively. At 4, 8, 12 and 24 hours postoperatively the pain scores were significantly lower (P<0.05%) for Group 3 compared with Group 2. Group 4 had the lowest pain scores over the recorded period compared with the other groups. The need for supplemental analgesia was significantly lower (P<0.05) in the treatment Groups 2, 3 and 4 compared to the control Group 1. There was no significant difference in supplemental analgesic requirements between Groups 2, 3 and 4. A combination of bupivacaine and morphine injected intra-articularly following arthroscopy provided superior analgesia compared with that achieved by either drug alone.
SummaryDuring transcervical endometrial resection the uterine cavity is irrigated under pressure with 1.5% glycine solution. This solution m a y be absorbed, with consequent fluid and electrolyte shijts. Plasma sodium concentration was analysed in 21 women undergoing transcervical endometrial resection and decreased in every case. In jive cases this decrease was > 10mmol.l-'. Hyponatraemia is a potential risk with this procedure.Key words Surgery; transcervical endometrial resection. Complications; hyponatraemia.It has been recognised for many years that the use of hypotonic solutions for the irrigation of the bladder cavity during transurethral resection of the prostate (TURP) can result in absorption of the solution from the exposed prostatic bed and subsequent fluid and electrolyte shifts [I]. In patients with TURP syndrome, symptoms may appear as the plasma sodium concentration decreases to less than 135 mmol.l-'. Most clinical reactions occur when the sodium decreases by 15-20 mmol.1-l and a plasma sodium concentration of 120 mmol.1-l has been regarded as the level distinguishing moderate from severe reactions [2-41. Symptoms of hyponatraemia are related to the speed of its development, acute changes producing more symptoms than chronic [5]. Electrocardiographic changes, characterised by a widening of the QRS complex and ST elevation, may occur when the sodium falls to 115 mmol.1-'. Convulsions and ventricular tachycardia or fibrillation may occur at plasma sodium levels below 100 mmol.1-l [4].Hysteroscopic transcervical endometrial resection (TCER) with the use of diathermy was first reported by DeCherney and Polan in 1983 [6] and is now an alternative to hysterectomy for women with menorrhagia. Advantages of the technique include a shorter operative time and rapid postoperative recovery and discharge. The procedure involves the use of a cutting loop diathermy to resect the endometrium while the uterine cavity is continuously irrigated with a 1.5% glycine solution. As the uterine cavity is less compliant than the bladder, the irrigation pressures used are greater than during TURP. The aim of this study was to measure the changes in plasma sodium associated with TCER to assess whether fluid absorption is clinically significant.Following completion of the study a case of fluid absorption during TCER occurred, which demonstrated the potential hazard. Details of this case are presented to illustrate the problem. MethodsFollowing ethics committee approval and informed consent, 21 women of ASA grade 1 or 2 presenting for endometrial resection were included in the study. All patients received a standard temazepam premedication. Prior to anaesthesia 10 ml of blood was collected from each patient. The anaesthetic technique consisted of fentanyl 2 pg.kg-l, thiopentone 5 mg.kg-I, and vecuronium 0.1 mg.kg-l. Following tracheal intubation, patients were ventilated with nitrous oxide/oxygen and isoflurane 0.5-1 ?LO to an end-tidal carbon dioxide of 4.5-5 kPa.Intravenous fluids were not administered and monitoring cons...
not easy to explain, there is experimental data suggesting that testosterone can influence neuromuscular transmission in the diaphragm of rats [2, 3]. Furthermore, it was seen after shorter rather than longer periods of treatment (2.5 weeks vs. 10 weeks) [4].We wished to highlight the problem of handling an increased catabolic state (of different origins) -or even a risk of it -in patients with primary or secondary male hypogonadism. This situation is often unnoticed and its influence on the body sometimes underestimated. In our opinion, the concentration of testosterone in serum should be restored in all hypogonadal patients in possible catabolic states. It is especially valid for males who have received high doses of anabolic-androgenic steroids for a long time. We believe that before major surgical procedures, the testosterone level should be maintained above the normal range. We also wonder whether such management should be considered before surgical procedures in males with andropausal hypogonadism (with low levels of total and free testosterone).
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