SummaryWe describe a patient with type 2N von Willebrand's disease scheduled for elective coronary artery bypass graft for severe three-vessel coronary artery disease with involvement of the left main stem. He was given a pre-operative bolus of 3000 IU factor VIII ⁄ Willebrand factor concentrate ( 40 IU.kg )1 ), followed by a continuous infusion of 3 IU.h )1 (228 IU.h )1 ) before undergoing coronary surgery with full heparinisation and cardiopulmonary bypass. There were no intraoperative bleeding complications and only one unit of packed red blood cells was required postoperatively. Thromboprophylaxis with low-molecular weight heparin and aspirin was given and the infusion of factor VIII ⁄ von Willebrand factor concentrate continued for 2 days. As a result of haematological monitoring, heparin therapy was changed from prophylactic to therapeutic on day 5-6 and stopped on day 7. The management of adult patients with von Willebrand's disease has only marginally been described in the available literature since 1983, especially in the context of coronary artery bypass graft. This reflects the small number of patients with an established diagnosis of von Willebrand's disease and the even smaller number of these presenting for open heart surgery. We describe the peri-operative management of a patient with type 2N von Willebrand's disease presenting for coronary artery bypass graft. A literature search revealed a few studies reporting the association of aortic stenosis and acquired von Willebrand's disease [1-3], but only one report in the anaesthetic literature [4], and two reports in the non-anaesthetic literature describing heart surgery in children [5,6]. Only a few details about management of this bleeding disorder have been offered [4,7,8].
Case reportA 75-year-old male patient was scheduled for elective coronary artery bypass graft for severe three-vessel coronary artery disease with involvement of the left main stem. The patient was known for many years to have type 2N von Willebrand's disease and was under the care of the haematology service of the University Medical Center, Utrecht.On the early morning of the day of surgery his factor VIII baseline activity was 53%, von Willebrand factor antigen 29% and von Willebrand factor ristocetin 16%. According to the peri-operative protocols of our haematology service a pre-operative bolus of 3000 IU factor VIII ⁄ Willebrand factor concentrate (Haemate-P ) was then commenced and the patient proceeded to coronary surgery with full heparinisation and cardiopulmonary bypass. Intra-operatively, no bleeding complications occurred and administration of blood products was not deemed necessary. Postoperatively the patient was transferred to the intensive care unit (ICU) for further care with the
A patient recently treated with surgery and radiation for oropharyngeal cancer presented with impending hypoxic respiratory and cardiac arrest in a difficult airway scenario. A CriCath cannula in combination with the Ventrain device and its active expiratory ventilation technology enabled oxygenation and ventilation for 60 minutes until a surgical airway was established. This case report is the first to describe the intended use of Ventrain technology in an emergent "can't ventilate-can't intubate" scenario.
Peripherally inserted central catheters are being used in increasing numbers. Common (thrombosis, infection, phlebitis, malfunction, or disconnection) and rare complications (pericardial tamponade) have been well explored. We describe 2 serious complications that resolved without sequelae. Both complications occurred in the context of limited provider competence. We conclude that vascular access is more than "just" placing a catheter; it can have serious clinical impact and has evolved into a specialist skill. With increasing use of intravascular catheters, the need for a formalized training becomes urgent.
We report on a 36 year old patient who collapsed at home and was resuscitated by prehospital medical emergency services. He presented on scene unconscious with severe ST-elevations on the ECG and hardly palpable pulses. His previous medical history included only idiopathic hypertension and his professional background as manager of a company was associated with high stress levels. The prehospital diagnosis was myocardial infarction with cardiogenic shock. A hypovolemic shock was excluded from the differential diagnosis because of the age of the patient, lack of a precipitating trauma and inconsistent symptoms. The patient died after terminating prolonged resuscitation. A post mortem showed as cause of death the rupture of a splenic artery aneurysm. We emphasize that a cardiovascular collapse in a young patient without specific history or trauma still can be caused by hypovolemic shock due to intra-abdominal or -thorac bleeding.
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