Fatal rhabdomyolysis and disseminated intravascular coagulation after total knee arthroplasty under spinal anesthesia: A case report.

BACKGROUND: Rhabdomyolysis develops as a result of skeletal muscle cell collapse from leakage of the intracellular contents into circulation. In severe cases, it can be associated with acute kidney injury and disseminated intravascular coagulation, leading to life threatening outcomes. Rhabdomyolysis can occur in the perioperative period from various etiologies but is rarely induced by tourniquet use during orthopedic surgery. CASE SUMMARY: A 77-year-old male underwent right total knee arthroplasty using a tourniquet under spinal anesthesia. About 24 h after surgery, he was found in a drowsy mental state and manifested features of severe rhabdomyolysis, including fever, hypotension, oliguria, high creatine kinase, myoglobinuria, and disseminated intravascular coagulation. Despite supportive care, cardiac arrest developed abruptly, and the patient was not able to be resuscitated. CONCLUSION: Severe rhabdomyolysis and disseminated intravascular coagulation can develop from surgical tourniquet, requiring prompt, aggressive treatments to save the patient.

The effects of sevoflurane with propofol and remifentanil on tracheal intubation conditions without neuromuscular blocking agents.

BACKGROUND: Propofol and remifentanil are used for tracheal intubation in the absence of neuromuscular blocking agents. We hypothesized that the addition of sevoflurane to propofol and remifentanil would improve intubation conditions and provide hemodynamic stability. METHODS: Seventy-six patients scheduled for elective surgery were randomly allocated to be ventilated with either 4% (group I) or 7% sevoflurane (group II) after propofol injection (2 mg/kg). All patients received remifentanil (1 microg/kg) 30 seconds after administration of propofol. Ninety seconds after remifentanil was given, laryngoscopy and tracheal intubation were performed. Intubation conditions and hemodynamic changes were evaluated. RESULTS: The overall incidence of clinically acceptable intubation conditions was significantly higher in group II (92%) than group I (58%) (P = 0.001). Scores for vocal cord position, coughing, and limb movement were significantly better in group II (P < 0.05). Mean blood pressure remained significantly lower than the pre-induction level throughout the investigation in both groups (P < 0.001), but there was no incidence of bradycardia or hypotension requiring treatment. CONCLUSIONS: Tracheal intubation without neuromuscular blocking agents can be achieved safely and reliably by adding 7% sevoflurane to propofol (2 mg/kg) and remifentanil (1 microg/kg).

Lymphangiomatosis involving the inferior vena cava, heart, pulmonary artery and pelvic cavity.

A 38-year-old woman who had undergone pelvic lymphangioma resection two months previously presented with cough and dyspnea. Transthoracic echocardiography and CT demonstrated the presence of a mixed cystic/solid component tumor involving the inferior vena cava, heart and pulmonary artery. Complete resection of the cardiac tumor was performed and lymphangioma was confirmed based on histopathologic examination. To the best of our knowledge, this is the first report of lymphangiomatosis with cardiac and pelvic involvement in the published clinical literature.

Stress-induced cardiomyopathy following cephalosporin-induced anaphylactic shock during general anesthesia.

PURPOSE: Anaphylaxis may be caused by various agents during general anesthesia. Sympathetic discharge may occur during anaphylaxis, which can trigger transient cardiomyopathy. We describe a case of stress-induced cardiomyopathy that occurred in association with an anaphylactic reaction during general anesthesia. CLINICAL FEATURES: A 32-year-old female undergoing laparoscopic enucleation of an ovarian cyst developed a severe anaphylactic reaction after cephalosporin infusion during general anesthesia. Her vital signs responded favourably to immediate resuscitative maneuvers, but cardiovascular collapse reappeared with transient ventricular tachycardia shortly after her transfer to the intensive care unit. ST-segment elevation appeared in electrocardiographic leads V(2)-V(6) and echocardiography showed diffuse regional wall motion abnormalities in the midventricular level. Increased MB fractions of creatine kinase and troponin T levels indicated myocardial necrosis, but cardiac catheterization demonstrated normal coronary arteries. Management was supportive and she was discharged 2 days after the onset of anaphylactic symptoms, without sequelae. A diagnosis of stress-induced cardiomyopathy of a midventricular type following anaphylaxis was made on the basis of the clinical features and the findings of cardiac evaluations. CONCLUSIONS: Transient, reversible left-ventricular dysfunction is a recently recognized phenomenon that may occur in the setting of anaphylactic reactions during the perioperative period.