Severe neurological complications of post open heart surgery: the Jamaican experience; January, 1994 - August, 1999

Neurological complications after open-heart surgery (OHS) constitute a broad spectrum of injury, and represents the leading cause of morbidity and mortality. The most serious injury is seen in those who remain comatose or never regain meaningful neurologic function. Stroke is another devastating complication that can leave the patient permanently disabled. The incidence of stroke has been documented as ranging from 0.8 - 5.2 percent. Much less information is available on the incidence of the less fatal complications such as delirium, confusion, encephalopathy, developmental delay or other neuropsychiatric disorders. During the period January, 1994 to August, 1999, a total of 360 paitents (adults and children) underwent OHS, at the University Hospital of the West Indies (UHWI), Mona, Jamaica. The types of surgeries performed were: ASD = 53; VSD = 40; valve replacement = 151 (100 MVR, 34 AVR, 17 DVR); valvuloplasty/annuloplasty = 5; CABG = 44; repair of congenital heart abnormalities = 65; other (atrial myxoma) = 2. About eight (8) patients (2.2 percent) developed severe neurological symptoms post-operatively. These ranged from short period (<24 hours) of seizure activities to severe encephalopathy and death, secondary to massive cerebral infarction. Four (4) of these patients died as a result of the neurologic complication. There is no need for avoidance and/or elimination of the factors that increase the risk of post-operative neurologic complications. Unfortunately not all of these can be eliminated. There is also the need for detailed, structured neurological and neuropsychiatric assessments, both pre- and post-operatively. These will enable the early detection of gross, but more importantly the subtle changes and hence prompt institution of counteractive/corrective measure. Detection of markers which will indicate the possible development of severe neurologic injury would also be useful.(AU)

Myxedema coma

Only once was this condition found in over 5,500 admissions during a five year period. This case report commented on the clinical features, the laboratory findings as well as the response to thyroid extract (AU)

Coma in myxedema

The clinical features as well as the changes in serum electrolytes and electro-encephalogram were presented. The histological changes noted in the brain were non specific (AU)

Clinical studies on South Trinidadian children: IV Hypoglycaemia in rum poisoning

In a period of six months, a general hospital admitted seven children who had been poisoned with rum and five of them were found to be hypoglycaemic. The administration of glucose was followed by recovery which was instantaneous in one and rapid in two others. Two cases died despite treatment. The occurrence of severe hypoglycaemia in acute alcoholism in children is recognised but unexplained. Recent experience here suggest that this reversible complication should be sought in children poisoned with alohol and some other substances. It appears that rum should be added to the list of causes of acute toxic hypoglycaemia in childhood (AU)

Severe Neurological complications post-open heart surgery: the Jamacian experience

During the period January 1994 to December 1999, a total of 395 patients - adults and children - underwent various types of open heart surgical (OHS) procedures. The range of these patients was 10 days to 77 years. Most (43.5 percent) of these patients underwent valve replacement - first time and "redo" - as a result of rheumatic heart disease of varying duration and severity. The other large group was the complex congenital heart abnormalities (16 percent), followed by the group that underwent repair of atrial septal defect (13 percent), coronary artery bypass graft (13 percent) and repair of the ventricular septal defect (12 percent). Open valve repair (2 percent) developed severe neurological complications (NCs) post-OHS. These included: a short period (< 48 hours) of irritability and fluctuating consiousness level; seizure activity associated with hemiparesis and/or blindness; severe encephalopathy and vegetative state. Four patients showed complete recovery, but one died as a result of complications of the anti-seizure medication. Of the five, four died as a result of the NCs, and one was discharged in a vegetative state. Such severe neurological complications after an otherwise successful cardiac surgery represented a devastating outcome for patients and their families, and the social and economic impacts are enormous. Several factors were identified. The main ones being mitral valve replacement (MVR), especially "redo" surgery, female gender, age over 60 years, high New York Association functional class and post-operative hypotension. However, the true incidence of NCs (gross and subtle) in the study group cannot be ascertained. A detailed, structured neurological and neuropsychiatric assessment, both pre-and post-operatively, is therefore needed to document the true incidence of this complication. There is also the need for public education, especially for those with valvular disease, in order to encourage changes in attitude and behaviour towards continued follow-up care and valve surgery, both first and `redo'. (AU)