Cerebellar Hemorrhage and Spinal Fluid Overdrainage With Tonsillar Herniation Following Spine Surgery.

Spinal fluid overdrainage with cerebellar hemorrhage is a rare complication of spinal surgery that can have severe consequences if not detected quickly. We present the case of a 72-year-old Caucasian female who underwent thoracolumbar fixation for flatback syndrome. Intraoperatively, the patient suffered a dural injury that was repaired. In the immediate postoperative period, the patient's neurological status rapidly deteriorated within an hour and Jackson-Pratt (JP) drain output measured 300 ml of serosanguinous fluid. A stat CT scan revealed cerebellar hemorrhage, pneumocephalus, and tonsillar herniation. The postoperative drain was immediately removed, and a ventriculostomy tube was placed, confirming low intracranial pressure. Postoperatively, the patient was electively ventilated for three days, continued with remote cerebellar hemorrhage (RCH) treatment and precaution, and extubated on the third day as the patient's neurological function continued to improve. The patient was discharged home nine days after the initial surgery, with a complete recovery. This case indicates that wound drainage in the face of durotomy can induce cerebellar herniation as early as within an hour postoperatively following spine surgery with a dural tear, even after dural repair. This case also suggests that early recognition and appropriate management of RCH is the key to a full recovery. Even in the event of tonsillar herniation and cerebellar hemorrhage, a complete recovery is possible with early recognition and proper management.

The kaolin-activated Thrombelastograph predicts bleeding after cardiac surgery.

OBJECTIVE: The objective of this study was to determine the relationship of the kaolin-activated Thrombelastograph (TEG) with postoperative bleeding and laboratory tests of coagulation in the setting of cardiac surgery with the routine use of -aminocaproic acid. DESIGN: Prospective observational study. SETTING: An adult heart center at a tertiary referral, university hospital. PARTICIPANTS: Thirty adult cardiac surgical patients. INTERVENTIONS: The kaolin-activated TEG, platelet counts, prothrombin times, activated partial thromboplastin times, and fibrinogen levels were measured before induction of anesthesia, during cardiopulmonary bypass, and on arrival in the intensive care unit. Mediastinal and thoracostomy drainage were measured every hour for 4 hours after arrival in the intensive care unit. MEASUREMENTS AND MAIN RESULTS: Correlation and multivariate linear regression modeling were used to describe relationships among coagulation tests, TEG parameters, and early postoperative bleeding. The TEG maximum amplitude (MA) parameter correlated well with postoperative bleeding (r = -0.6, p = 0.0018), more so than platelet count (r = -0.45, p = 0.02), fibrinogen level (r = -0.40, p = 0.06), or prothrombin time (r = 0.43, p = 0.02). The receiver operating characteristic curve c-index describing MA as a predictor for postoperative bleeding is 0.78. Abnormalities in all the laboratory test results were associated with an abnormal MA. CONCLUSIONS: In conclusion, the kaolin-activated TEG is associated with early coagulopathic bleeding. It may reflect the severity of a global coagulopathy affecting both platelets and coagulation factors and be a guide to incremental prohemostatic therapy in this setting.

Pharmacodynamic interactions between cisatracurium and rocuronium.

UNLABELLED: The onset and duration of maintenance doses of neuromuscular blocking drugs may be influenced by the original neuromuscular blocking drug used. We assessed the effect of the interaction between steroidal and benzo-isoquinolinium compounds on the clinical duration of maintenance doses of cisatracurium. Sixty adult patients undergoing anesthesia with isoflurane, nitrous oxide, and oxygen were randomized to receive the following: Group I = rocuronium 0.6 mg/kg followed by cisatracurium 0.03 mg/kg when the first twitch in the train-of-four (TOF) recovered to 25%, Group II = cisatracurium 0.15 mg/kg followed by cisatracurium 0.03 mg/kg, and Group III = rocuronium 0.6 mg/kg followed by rocuronium 0.15 mg/kg. Neuromuscular blockade was monitored using acceleromyography (TOF-Guard, Boxtel, The Netherlands). The clinical duration (mean +/- SD) of the first 2 maintenance doses was 41 +/- 10, 31 +/- 7++, and 25 +/- 8++ min, and 39 +/- 11, 30 +/- 6+, 29 +/- 9* min in Groups I-III, respectively (*P < 0.05, +P < 0.01, ++P < 0.001; Group I versus II and III). Thus, the clinical duration of the first two maintenance doses of cisatracurium was prolonged when administered after rocuronium. IMPLICATIONS: We assessed the clinical effect of administering cisatracurium after an intubating dose of rocuronium in 60 patients undergoing isoflurane/nitrous oxide and oxygen anesthesia. The clinical duration of the first two maintenance doses of cisatracurium administered after rocuronium was significantly prolonged. This supports the contention that combinations of structurally dissimilar neuromuscular blocking drugs result in a synergistic effect.