Seizure due to multiple drugs intoxication: a case report / Convulsão por causa de intoxicação por múltiplas drogas: relato de caso

Abstract The mechanism of the antidepressant effect of bupropion is not fully understood. Besides, using it in the treatment of depression, it is found to be effective in reducing withdrawal symptoms due to smoking cessation. A 28-year-old female patient with a history of depression was admitted to emergency department an hour after ingestion of bupropion, quetiapine, and levothyroxine in high doses to commit suicide. While accepting her into the Intensive Care Unit, she was awake, alert, disoriented and agitated. After 2 h, the patient had a generalized tonic-clonic seizure. The necessary treatment was given and 9 h later with hemodynamic improvement, the patients’ mental status improved. Bupropion may cause unusual behaviors such as delusions, paranoia, hallucinations, or confusion. The risk of seizure is strongly dose-dependent. We want to emphasize the importance of early gastric lavage and administration of activated charcoal.

Resumo O mecanismo do efeito antidepressivo de bupropiona ainda não está bem esclarecido. Contudo, seu uso no tratamento de depressão revelou ser eficaz para reduzir os sintomas de abstinência relacionados à cessação do tabagismo. Uma paciente do sexo feminino, 28 anos, com história de depressão, deu entrada no setor de emergência uma hora após a ingestão de bupropiona, quetiapina e levotiroxina em doses elevadas para cometer suicídio. Ao ser internada em unidade de terapia intensiva, estava acordada, alerta, desorientada e agitada. Após duas horas, apresentou uma crise tônico-clônica generalizada. O tratamento necessário foi administrado e nove horas mais tarde, com a estabilização hemodinâmica, o estado mental da paciente melhorou. Bupropiona pode causar comportamentos incomuns, incluindo delírios, paranoia, alucinações ou confusão mental. O risco de convulsão é altamente dependente da dose. Queremos enfatizar a importância da lavagem gástrica precoce e da administração de carvão ativado.

Seizure due to multiple drugs intoxication: a case report.

The mechanism of the antidepressant effect of bupropion is not fully understood. Besides, using it in the treatment of depression, it is found to be effective in reducing withdrawal symptoms due to smoking cessation. A 28-year-old female patient with a history of depression was admitted to emergency department an hour after ingestion of bupropion, quetiapine, and levothyroxine in high doses to commit suicide. While accepting her into the Intensive Care Unit, she was awake, alert, disoriented and agitated. After 2h, the patient had a generalized tonic-clonic seizure. The necessary treatment was given and 9h later with hemodynamic improvement, the patients' mental status improved. Bupropion may cause unusual behaviors such as delusions, paranoia, hallucinations, or confusion. The risk of seizure is strongly dose-dependent. We want to emphasize the importance of early gastric lavage and administration of activated charcoal.

Effect of intraoperative esmolol infusion on anesthetic, analgesic requirements and postoperative nausea-vomitting in a group of laparoscopic cholecystectomy patients / Efeito da infusão de esmolol sobre a necessidade de anestesia no intraoperatório e analgesia, náusea e vômito no pós-operatório em um grupo de pacientes submetidos à colecistectomia laparoscópica / Efecto de la infusión de esmolol sobre la necesidad de anestesia en el intraoperatorio y analgesia, náuseas y vómito en el postoperatorio en un grupo de pacientes sometidos a la colecistectomía laparoscópica

PURPOSE: Postoperative pain and nausea/vomitting (PNV) are common in laparoscopic cholecystectomy patients. Sympatholytic agents might decrease requirements for intravenous or inhalation anesthetics and opioids. In this study we aimed to analyze effects of esmolol on intraoperative anesthetic-postoperative analgesic requirements, postoperative pain and PNV. METHODS: Sixty patients have been included. Propofol, remifentanil and vecuronium were used for induction. Study groups were as follows; I - Esmolol infusion was added to maintenance anesthetics (propofol and remifentanil), II - Only propofol and remifentanil was used during maintenance, III - Esmolol infusion was added to maintenance anesthetics (desflurane and remifentanil), IV - Only desflurane and remifentanil was used during maintenance. They have been followed up for 24 h for PNV and analgesic requirements. Visual analog scale (VAS) scores for pain was also been evaluated. RESULTS: VAS scores were significantly lowest in group I (p = 0.001-0.028). PNV incidence was significantly lowest in group I (p = 0.026). PNV incidence was also lower in group III compared to group IV (p = 0.032). Analgesic requirements were significantly lower in group I and was lower in group III compared to group IV (p = 0.005). Heart rates were significantly lower in esmolol groups (group I and III) compared to their controls (p = 0.001) however blood pressures were similar in all groups (p = 0.594). Comparison of esmolol groups with controls revealed that there is a significant decrease in anesthetic and opioid requirements (p = 0.024-0.03). CONCLUSION: Using esmolol during anesthetic maintenance significantly decreases anesthetic-analgesic requirements, postoperative pain and PNV. .

OBJETIVO: A dor e a incidência de náusea e vômito no período pós-operatório (NVP) são comuns em pacientes submetidos à colecistectomia laparoscópica. Os agentes simpatolíticos podem diminuir a necessidade de opiáceos ou anestésicos inalatórios ou intravenosos. Neste estudo, nosso objetivo foi analisar os efeitos de esmolol sobre a necessidade de anestésico no período intraoperatório e de analgésico no pós-operatório e a incidência de dor e NVP. MÉTODOS: Sessenta pacientes foram incluídos. Propofol, remifentanil e vecurônio foram usados para a indução. Os grupos de estudo foram os seguintes: grupo I, a infusão de esmolol foi adicionada aos anestésicos (propofol e remifentanil) para manutenção; grupo II, apenas propofol e remifentanil foram usados durante a manutenção; grupo III, a infusão de esmolol foi adicionada aos anestésicos (desflurano e remifentanil) para manutenção; grupo IV, apenas desflurano e remifentanil foram usados durante a manutenção. O período de acompanhamento foi de 24 horas para avaliar a incidência de NVP e a necessidade de analgésicos. Os escores de dor também foram avaliados por meio da escala visual analógica (EVA). RESULTADOS: Os escores EVA foram significativamente menores no grupo I (p = 0,001-0,028). A incidência de NVP foi significativamente menor no grupo I (p = 0,026). NVP também foi menor no grupo III em relação ao grupo IV (p = 0,032). A necessidade de analgésicos foi significativamente menor no grupo I e menor no grupo III em relação ao grupo IV (p = 0,005). A frequência cardíaca foi significativamente menor nos grupos esmolol (grupos I e III) comparados com os controles (p = 0,001), mas a pressão arterial foi semelhante em todos os grupos (p = 0,594). A comparação entre os grupos esmolol e controles revelou que houve uma diminuição. CONCLUSÃO: O uso de esmolol durante a manutenção da anestesia reduz significativamente a necessidade de anestésico-analgésico, dor e incidência de NVP. .

OBJETIVO: El dolor y la incidencia de náuseas y vómito en el período postoperatorio (NVPO) son comunes en pacientes sometidos a colecistectomía laparoscópica. Los agentes simpaticolíticos pueden disminuir la necesidad de opiáceos o anestésicos inhalatorios o intravenosos. En este estudio, nuestro objetivo fue analizar los efectos del esmolol sobre la necesidad de anestésico en el período intraoperatorio y de analgésico en el postoperatorio y la incidencia de dolor y NVPO. MÉTODOS: Sesenta pacientes fueron incluidos. Para la inducción fueron usados el propofol, el remifentanilo y el vecuronio. Los grupos de estudio fueron los siguientes: grupo I, la infusión de esmolol fue añadida a los anestésicos (propofol y remifentanilo) para el mantenimiento; grupo II, durante el mantenimiento solamente fueron usados el propofol y el remifentanilo; grupo III, la infusión de esmolol fue añadida a los anestésicos (desflurano y remifentanilo) para mantenimiento; grupo IV, solamente fueron usados durante el mantenimiento el desflurano y el remifentanilo. El período de acompañamiento fue de 24 h para calcular la incidencia de NVPO y la necesidad de analgésicos. Las puntuaciones de dolor también fueron evaluadas mediante la escala visual analógica. RESULTADOS: Las puntuaciones de la escala visual analógica fueron significativamente menores en el grupo I (p = 0,001-0,028). La incidencia de NVPO fue significativamente menor en el grupo I (p = 0,026). NVPO también fue menor en el grupo III con relación al grupo IV (p = 0,032). La necesidad de analgésicos fue significativamente menor en el grupo I y menor en el grupo III con relación al grupo IV (p = 0,005). La frecuencia cardíaca fue significativamente menor en los grupos esmolol (grupos I y III) comparados con el control (p = 0,001), pero la presión arterial fue similar en todos los grupos (p = 0,594). La comparación entre los grupos esmolol y control reveló que hubo una disminución significativa de la necesidad ...

[Effect of intraoperative esmolol infusion on anesthetic, analgesic requirements and postoperative nausea-vomitting in a group of laparoscopic cholecystectomy patients]. / Efeito da infusão de esmolol sobre a necessidade de anestesia no intraoperatório e analgesia, náusea e vômito no pós-operatório em um grupo de pacientes submetidos à colecistectomia laparoscópica.

PURPOSE: Postoperative pain and nausea/vomitting (PNV) are common in laparoscopic cholecystectomy patients. Sympatholytic agents might decrease requirements for intravenous or inhalation anesthetics and opioids. In this study we aimed to analyze effects of esmolol on intraoperative anesthetic-postoperative analgesic requirements, postoperative pain and PNV. METHODS: Sixty patients have been included. Propofol, remifentanil and vecuronium were used for induction. Study groups were as follows; I - Esmolol infusion was added to maintenance anesthetics (propofol and remifentanil), II - Only propofol and remifentanil was used during maintenance, III - Esmolol infusion was added to maintenance anesthetics (desflurane and remifentanil), IV - Only desflurane and remifentanil was used during maintenance. They have been followed up for 24h for PNV and analgesic requirements. Visual analog scale (VAS) scores for pain was also been evaluated. RESULTS: VAS scores were significantly lowest in group I (p=0.001-0.028). PNV incidence was significantly lowest in group I (p=0.026). PNV incidence was also lower in group III compared to group IV (p=0.032). Analgesic requirements were significantly lower in group I and was lower in group III compared to group IV (p=0.005). Heart rates were significantly lower in esmolol groups (group I and III) compared to their controls (p=0.001) however blood pressures were similar in all groups (p=0.594). Comparison of esmolol groups with controls revealed that there is a significant decrease in anesthetic and opioid requirements (p=0.024-0.03). CONCLUSION: Using esmolol during anesthetic maintenance significantly decreases anesthetic-analgesic requirements, postoperative pain and PNV.

Effect of laryngoscopy on middle ear pressure during anaesthesia induction.

AIMS: The procedure of laryngoscopic orotracheal intubation (LOTI) has many impacts on several parts of the body. But its effect on middle ear pressure (MEP) is not known well. The purpose of this study is to evaluate the MEP changes subsequent to insertion of endotracheal tube with laryngoscope. SUBJECTS AND METHODS: 44 patients were included in this study with a normal physical examination of ear, nose and throat. A standard general anaesthesia induction without any inhaler agent was performed to the all patients. The MEP measurements for both ears were applied under 1 minute; before induction (BI) and after intubation (AI) with a middle ear analyzer. Also hemodynamic parameters were recorded before induction and after intubation. RESULTS: Of the 44 patients were 25 women and 19 men with a 43.5±15.1 mean age. A statistically significant rise in MEP was seen in all patients subsequent to insertion of endotracheal tube (P<0.05). Mean right MEPs were BI: -9.5 and AI: 18.5 daPa. Also mean left MEPs were BI: -21.7 and AI: 29.1 daPa. The amount of increases in left and right MEPs were 50 daPa and 27 daPa, respectively. 20% increase in systolic blood pressure and 19% increase in diastolic blood pressure were determined after intubation. The mean heart rate was 76/min before intubation, whereas it was 102/min after intubation with a 34% increase. CONCLUSION: In this study bilateral significant increases in MEP were determined subsequent to LOTI. Possible factors affecting MEP may be auditory tube, size and type of the blades, drugs and face masking time. But on the other hand in our opinion cardiovascular and haemodynamic response to LOTI has the most impact over the middle ear mucosa with mucosal venous congestion.

Investigation of middle ear pressure changes during prone position under general anesthesia without using nitrous oxide.

PURPOSE: The effects of different body positions on the middle ear were reported in several studies, but there are no data about the effects on patients under general anesthesia. The aim of this study is to determine the effect of prone position on middle ear pressure (MEP) during general anesthesia without using nitrous oxide. METHODS: Twenty patients under general anesthesia during prone position were included in the study. The performed anesthesia method was the same for all patients. Remifentanil was used for analgesia instead of nitrous oxide. MEPs were measured 5 times with a middle ear analyzer: before induction (BI), after intubation (AI), after turned to the prone position (PP1), at the end of the prone position (PP2), and after returned to the supine position (SP). Duration of prone position was also recorded. RESULTS: Of the 20 patients were 11 women and 9 men with a 49 ± 13 mean age. BI-AI, AI-PP1, PP1-PP2, and PP2-SP comparisons of both MEPs were statistically significant (P < 0.0001). Right mean MEPs were BI, -1 ± 23 daPa; AI, 41 ± 51 daPa; PP1, 124 ± 76 daPa; PP2, 152 ± 59 daPa; and SP, 63 ± 29 daPa; whereas left mean MEPs were BI, -24 ± 55 daPa; AI, 28 ± 34 daPa; PP1, 132 ± 67 daPa; PP2, 162 ± 48 daPa; and SP, 70 ± 89 daPa. Significant increases were detected at the start and continuation of the prone position. The mean duration of prone position was 98 ± 51 per minute. CONCLUSIONS: The significant MEP increases during the prone position under general anesthesia depend on a number of reasons. Among them are inhaler agents, pressure changes in mucosal blood vessels due to venous congestion, and the mastoid bone volume. Further researches are required to determine and explain the mechanisms of increase in MEP during prone position.