SummaryA 57-year-old man with recurrent depression, resistant to drug therapy, was scheduled for a course of eight electroconvulsive therapy treatments. The patient had undergone seven treatments without incident over the previous 3 weeks. Immediately following the final treatment, the patient suffered cardiovascular collapse, culminating in cardiac arrest with electromechanical dissociation. Despite resuscitative measures, the patient died. Post-mortem examination found the cause of death to be cardiac tamponade, secondary to cardiac rupture.Keywords Anaesthesia; electroconvulsive therapy. Complication; death. Heart; rupture.. ..................................................................................... Correspondence to: Dr P. B. Ali Accepted: 13 March 1997 Electroconvulsive therapy (ECT) remains widely used in psychiatric practice. Primarily a treatment for endogenous depression resistant to drug therapy, it has been used with variable degrees of success in the treatment of other psychiatric disorders [1, 2]. It has been estimated that over 200 000 ECT treatments are performed each year in the UK [3]. Both the physical and the physiological consequences of the induced seizure are attenuated, to a variable degree, by provision of general anaesthesia and muscular paralysis; this 'modified ECT' is considered to be safe. While associated with minor morbidity, the estimated mortality is low and varies between 0.003 and 0.03% [1, 2]. Cardiovascular complications are the main cause of mortality. Case historyA 57-year-old male with a recurrent depression resistant to drug therapy was scheduled for a course of eight ECT treatments. Co-operative, although vague, the patient reported no serious medical problems and there were no adverse cardiac risk factors. Base line blood analyses were normal and the ECG showed sinus rhythm with normal axis and no evidence of conduction block or ischaemia. His medication at the time of treatment was carbamazepine 200 mg bd. and moclobemide 300 mg bd.Before each treatment the morning dose of moclobemide was omitted.Seven previous treatments had been completed without serious incident. For the final treatment, as before, intravenous access was secured and patient monitoring attached (noninvasive blood pressure, ECG and oximetry). After pre-oxygenation, anaesthesia was induced with etomidate 20 mg and a 40 mg dose of suxamethonium was given. Unilateral ECT was performed and resulted in a modified seizure lasting 27 s. An oropharyngeal airway was then inserted and manual ventilation of the lungs with high flow oxygen was continued.Shortly following treatment, the patient's face was noted to have become congested. This observation coincided with that of an unrecordable blood pressure and an impalpable carotid pulse. The ECG displayed sinus rhythm (rate of 112 beat.min -1) and the pulse oximeter registered 97% saturation. Electromechanical dissociation (EMD) was diagnosed and cardiac massage was immediately started. Despite efforts to resuscitate the patient, his ECG deteriorat...
After an accidental intra-arterial injection of thiopentone, good therapeutic results were obtained with a selective intra-arterial injection of urokinase during digital subtraction angiography.
Data on the effects of isovolemic hemodilution (IH) on oxygenation during one-lung ventilation (OLV) are lacking. We studied 47 patients with hemoglobin >14 g/dL who were scheduled for lung surgery (17 with normal lung function [group NL], 17 with chronic obstructive pulmonary disease [COPD] [group COPD], and 13 with COPD as control for time/anesthesia effects [group CTRL]). Anesthesia was standardized. The tracheas were intubated with a double-lumen tube. Ventilatory settings and fraction of inspired oxygen remained constant. The study was performed with patients in the supine position before surgery. OLV was initiated for 15 min. Two-lung ventilation was reinstituted, and IH was performed (500 mL); an identical volume of hydroxyethyl starch was administered. Subsequently, OLV was again performed for 15 min. In group CTRL, the same sequences of OLV were performed without IH. At the end of each period of OLV, pulmonary mechanics and blood gases were recorded. Data were analyzed by analysis of variance (mean +/- sd). In group NL and group CTRL, the arterial oxygen partial pressure remained constant, whereas it decreased in group COPD from 119 +/- 21 mm Hg before IH to 86 +/- 16 mm Hg after IH (P <0.01). Mild IH impairs gas exchange during OLV in COPD patients, but not in patients with normal lung function.
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