Perioperative Severe Anaphylaxis to Paracetamol in a Child.

The data on perioperative anaphylaxis (PA) in children is limited and usually reported with neuromuscular blocking agents and antibiotics. However we present a first pediatric case who developed PA with paracetamol unlike the literature.

Clinically suspected anaphylaxis induced by sugammadex in a patient with Weaver syndrome undergoing restrictive mammoplasty surgery: A case report with the literature review.

RATIONALE: Sugammadex is a cylodextrin derivate that encapsulates steroidal neuromuscular blocker agents and is reported as a safe and well-tolerated drug. In this case report, we present a patient who developed grade 3 anaphylaxis just after sugammadex administration. PATIENT CONCERNS: A 22-year-old woman with diagnosis of Weaver syndrome was scheduled for bilateral mammoplasty and resection of unilateral accessory breast tissue resection. Anesthesia was induced and maintained by propofol, rocuronium, and remifentanil. At the end of the operation, sugammadex was administered and resulted in initially hypotension and bradycardia then the situation worsened by premature ventricular contraction and bigeminy with tachycardia, bronchospasm, and hypoxia. DIAGNOSIS: The Ring and Messmer clinical severity scale grade 3 anaphylactic reaction occurred just after sugammadex injection and the patient developed prolonged hypotension with recurrent cardiac arrhythmias in postoperative 12 hours. INTERVENTIONS: Treatment was initiated bolus injections of ephedrine, epinephrine, lidocaine, steroids and antihistaminic and continued with lidocaine bolus dosages and norepinephrine infusion for the postoperative period. OUTCOMES: The general condition of the patient improved to normal 3 hours after the sugammadex injection, and she was moved to the intensive care unit. At 2nd and 8th hours of intensive care unit follow-up, she developed premature ventricular contraction and bigeminy with the heart rate of 130 to 135 beats/min, which returned to sinus rhythm with 50 mg lidocaine. After that, no symptoms were observed and the patient was discharged to plastic surgery clinic at the following day. LESSONS: Sugammadex may result in life-treating anaphylactic reaction even in a patient who did not previously expose to drug. Moreover, prolonged cardiovascular collapse and cardiac arrhythmias may occur.

Retrograde approach for percutaneous closure in a patient with ruptured sinus of Valsalva.

In this report, we present a 37-year-old male with ruptured right sinus of Valsalva. He was treated by percutaneous closure of the rupture using the retrograde approach. The procedure was performed successfully within 26 minutes. We think this approach may be used in future instead of the antegrade approach.

The efficiency and safety of percutaneous closure of secundum atrial septal defects with the Occlutech Figulla device: initial clinical experience.

OBJECTIVES: We evaluated the efficiency and safety of the Occlutech Figulla device in percutaneous closure of secundum atrial septal defects (ASD). STUDY DESIGN: The study included 28 patients (17 women, 11 men; mean age 43 years) who underwent percutaneous transcatheter closure using the Occlutech Figulla device for secundum ASDs causing a hemodynamically significant shunt. Defect size was estimated by transthoracic (TTE) and transesophageal (TEE) echocardiography, and also by balloon sizing in nine patients. The patients were followed-up for six months and were examined by TTE. RESULTS: The mean defect size was 20.3+/-2.1 mm on TTE, 22.1+/-1.9 mm on TEE, and 24.2+/-2.4 mm on balloon sizing. The mean device size was 26.8+/-3.6 mm (range 6 to 36 mm). The mean procedure time was 44.7+/-21.4 minutes. The device was placed successfully in all the patients. A small residual flow was seen immediately after device placement in three patients (10.7%), which disappeared in two patients at three months, and in one patient at six months. During the procedure, complications were seen in four patients (14.3%), including transient sinus tachycardia in three patients (10.7%) and acute atrial fibrillation in one patient (3.6%). At six months, all the patients were asymptomatic. No ischemic stroke, cardiac perforation, device erosion, embolization, thrombus formation, or malposition of the device were observed. CONCLUSION: The Occlutech Figulla occluder is a safe and efficient device to close secundum ASDs. It may be preferred especially in patients with a high risk for thrombus formation.

Hemodynamic effects, recovery profiles, and costs of remifentanil-based anesthesia with propofol or desflurane for septorhinoplasty.

OBJECTIVE: To compare hemodynamics, recovery profiles, postoperative side effects and costs of desflurane-remifentanil and propofol-remifentanil anesthesia for septorhinoplasty operations. METHODS: A prospective and randomized study was carried out at the Gazi University Hospital, Ankara, Turkey from April to September 2003. Forty patients undergoing septorhinoplasty operations were randomly allocated to receive desflurane-remifentanil (Group DES-REM) or total intravenous anesthesia (TIVA) (Group TIVA). Anesthesia was induced in both groups with remifentanil 1 microg x ml (-1), propofol 2-2.5 mg.kg-1 and pancuronium 0.1 mg.kg-1. Maintenance was achieved with O2 50% in air at 4 L.min-1 and infusion of remifentanil 0.1 microg x ml (-1).min-1 in both groups. Group DES-REM received desflurane at 1 minimum alveolar concentration and Group TIVA received 10-4 mg.kg-1.hour-1 of propofol. Propofol infusion and desflurane were discontinued with the last surgical stitches, but remifentanil infusion continued in both groups until the nose was covered with plaster. Hemodynamic variables were recorded during the operation and one hour postoperatively in 5 min intervals. We recorded time of extubation, spontaneous eye opening and response to verbal commands times, visual analog scale pain scores, postoperative nausea and vomiting and Aldrete Recovery Score. Drug dosages and costs of each technique were determined. RESULTS: There were no statistically significant differences between the groups with respect to hemodynamic parameters, recovery profile, adverse effects, Aldrete Recovery Score and cost analysis. Visual analog scale at 5 min postoperatively was higher in group desflurane-remifentanil compared to group propofol-remifentanil (p<0.05). CONCLUSION: Both desflurane-remifentanil and TIVA provide perioperative hemodynamic stability, early and easy recovery with similar cost profiles for septorhinoplasty operations.

Comparison of bupivacaine and ropivacaine on postoperative pain after tonsillectomy in paediatric patients.

BACKGROUND: We aimed to compare the effects of peritonsillar bupivacaine and ropivacaine infiltration on pain after tonsillectomy in children. METHOD: Sixty patients were randomly allocated to three groups: pertonsillar infiltration with bupivacaine (group B), ropivacaine (group R) and normal saline (group S). Pain scores with visual analogue scale (VAS) and sedation scores were assessed during postoperative 24h. Choice of additional analgesic was acetaminophen for all patients. RESULTS: VAS was significantly lower in groups B and R, during the first half hour, while it was lower in group B than those in groups R and S at postoperative second and sixth hours. Time to first analgesic treatment was significantly longer in groups B and R. Total acetaminophen consumption was lower in group B than those in group S. Sedation scores were higher in group B than in groups R and S until postoperative second hour but there were significant difference only at postoperative fifth minutes. CONCLUSION: Peritonsillar bupivacaine infiltration is, however, insufficient to control postoperative pain, it is more effective than ropivacaine for reducing postoperative analgesic requirement.

Hemodynamic and anesthetic advantages of dexmedetomidine, an alpha 2-agonist, for surgery in prone position.

The alpha2-agonist dexmedetomidine (Dex), a sedative and analgesic, reduces heart rate (HR) and blood pressure, and has been used in the practice of anesthesia. In this study, we aimed to evaluate the effects of Dex on hemodynamic variables, anesthetic sparing effects, and recovery profiles in patients who underwent surgery in prone position. The prone position itself can cause a decrease in the systemic blood pressure. Forty patients who undergo lumbar discectomy were randomly assigned to receive either Dex (a loading dose 1 microg/ kg in 10 minutes followed by an infusion rate of 0.2 microg/ kg/ hr) or saline. In both groups, the anesthesia was induced with fentanyl, thiopental and rocuronium, and maintained with desflurane in 50% N(2)O. Mean arterial blood pressure (MAP), HR, cardiac output (CO), and level of anesthesia were monitored. Recovery times and analgesic requirements were also recorded. As a response to endotracheal intubation, a significant increase in MAP and HR was observed in the control group compared to the Dex group, but no difference in CO. The recovery times were significantly shorter in the Dex group compared to the control group. Anesthetic and analgesic requirements of the Dex group were lower than controls. Thus, the use of Dex caused no detrimental effects on the hemodynamic variables in prone position. In addition, Dex decreased pressure response to intubation, and anesthetic and analgesic requirements, shortened recovery times, and decreased postoperative pain level. Dex may be an alternative to currently used adjunctive anesthetic agents in lumbar discectomy operations.