Papillary muscle rupture caused by bacterial endocarditis: role of transesophageal echocardiography.

A 22-year-old man had severe pulmonary congestion and required mechanical ventilation. Endocarditis was suspected because a 2/6 systolic murmur was heard at the apex and because Osler nodes were present. Transthoracic and transesophageal echocardiography allowed correct diagnosis of papillary muscle rupture causing massive mitral regurgitation. To our knowledge, this is the first reported case of papillary muscle rupture caused by bacterial endocarditis diagnosed by transthoracic and transesophageal echocardiography.

A comparison between lidocaine alone and lidocaine with meperidine for continuous spinal anesthesia.

BACKGROUND AND OBJECTIVES: Experimental investigations have demonstrated a synergistic interaction between opioids and local anesthetics. This study aims to assess the effective benefit-risk ratio of continuous spinal anesthesia (CSA) induced with either 1.6% lidocaine alone or in combination with 1% meperidine. METHODS: Thirty-four elderly patients (80.7 +/- 7.3 years) operated on for fracture of the neck of the femur were randomly allocated to two groups. In the first group (n = 15), CSA was induced with lidocaine 1.6% plain, whereas in the second group (n = 19) 1% meperidine was added. Reinjections were performed in both groups using lidocaine 1.6% alone. RESULTS: In the lidocaine group, 43 +/- 13 mg was used for induction whereas in the other group the addition of 18 +/- 5 mg of meperidine significantly reduced the dose of lidocaine required to 28 +/- 8 mg (p < 0.001). Delay between two reinjections was increased to 51 +/- 7 minutes in the lidocaine plus meperidine group, compared to 35 +/- 6 minutes in the lidocaine group (p < 0.001). Ephedrine was required for 9 out of the 19 patients in the lidocaine plus meperidine group, whereas it was required for only two patients in the other group (p = 0.05). Mean plasma concentrations of meperidine 1 hour and 3 hours after induction was 45.5 +/- 12 ng/ml and 59 +/- 22 ng/ml, respectively, and drowsiness was observed in 95% of the patients in the second group. Delay before requirement for pain medication was 2.2 +/- 2 hours in the lidocaine group and 14.1 +/- 8 hours in the lidocaine plus meperidine group (p < 0.001). CONCLUSIONS: The association of 1% meperidine with 1.6% lidocaine during the induction of CSA decreases the initial induction dose, prolongs analgesia, produces initial drowsiness, and provides long-lasting pain relief. However, such benefits are offset by some impairment of hemodynamic stability that is likely to make this combination of drugs unacceptable as an enhanced analgesic technique.