FloTrac/EV1000 guided management of amlodipine induced refractory hypotension during renal transplantation

Patients scheduled to undergo renal transplantation are often the most complex ones that an anaesthesiologist may encounter, as intraoperative hemodynamic instability can adversely affect the outcome of renal transplantation. Amlodipine is the commonly prescribed drug to patients with end stage renal disease [ESRD] for control of hypertension. Preoperative use of amlodipine may rarely present as intraoperative hypotension. Amlodipine induced hypotension is usually refractory to commonly used vasopressors. Combination of calcium, different sympathomimetic agents and fluids with minimal invasive monitoring with FloTrac/EV 1000 can be helpful in this situation. It is important to titrate antihypertensive medications in perioperative period to prevent intraoperative hemodynamic instability during renal transplantation as it can affect the graft function. We report a case of successful management of intraoperative refractory hypotension after therapeutic dose of amlodipine during renal transplantation

Bradycardia and severe vasospasm caused by intramyometrial injection of vasopressin during myomectomy

Vasopressin is often used locally to reduce blood loss during surgery. Vasopressin has longest clinical effect, but its systemic effects may be profound and pose significant challenges for the anesthesiologist and it can also sometimes cause lethal complications. The loss of peripheral pulse along with bradycardia, non-measurable arterial blood pressure, and cardiac complications have been reported after myometrial injection of vasopressin. Here, we describe a patient with multiple uterine myomas who developed severe bradycardia, non-measurable blood pressure by non-invasive means and loss of peripheral pulse after myometrial injection of vasopressin at a total dose of 20 units [1 unit/ml] with documentation of severe peripheral arterial vasospasm and increased proximal blood pressure. The patient was successfully resuscitated

Randomized double blind trial of intraperitoneal instillation of bupivacaine and morphine for pain relief after laparoscopic gynecological surgeries

Intraperitoneal injection of anesthetic has been proposed to minimize postoperative pain after laparoscopic surgery. So a randomized, placebo-controlled study was conducted to compare the effectiveness of intraperitoneal bupivacaine with or without morphine for postoperative analgesia after laparoscopic gynecological surgeries. A total of 90 ASA I and II female patients scheduled for laparoscopic gynecological procedures were enrolled in the randomized double blind prospective study. The drug was injected intraperitoneally before the removal of trocar at the end of surgery. In group BM [n=30]: 0.25% bupivacaine 30 ml + 2 mg morphine, in group BO [n=30] 30 ml 0.25% bupivacaine and in group C [n=30] 30 ml of saline was injected intraperitoneally. Postoperative quality of analgesia was assessed by VAS [0-100], for 24 hours and when VAS >40, rescue analgesic was administered. Total dose of rescue analgesia and side effects were noted. Intraperitoneal instillation of bupivacaine and morphine significantly reduces immediate postoperative pain [VAS: 23.33 +/- 6.04 vs. 45.5 +/- 8.57]. It also reduces pain at 4 hours after surgery in the BM group [VAS 24 +/- 12.13 vs. 41.17 +/- 7.27 in the BO group]. The time of administration of first rescue analgesic was significantly higher in the BM group [6.15 hours] compared to the BO group [4.51 hours]. The total dosage of rescue analgesic was more in the BO and C groups compared to the BM group. Addition of morphine to local anesthetic significantly prolonged the time to first rescue analgesic requirement and the total consumption of rescue analgesic in 24 hours without any significant increase in adverse events