Anaesthesia for scoliosis surgery in a patient on anticoagulant therapy.

Kyphoscoliosis surgery is frequently associated with major blood loss and coagulation disorders. A patient with juvenile rheumatoid arthritis, heart valve prosthesis and respiratory restrictive syndrome, was submitted to surgical correction of kyphoscoliosis. Current drug therapy included digitalis, oral anticoagulant and nonsteroidal anti-inflammatory drugs. After careful preoperative evaluation, oral anticoagulant and nonsteroidal anti-inflammatory drugs were discontinued (five and ten days before surgery, respectively), and intravenous heparin was introduced and maintained until two h before surgery. Bacterial endocarditis prophylaxis was obtained with ampicillin (50 mg.kg-1) and gentamicin (1.5 mg.kg-1). Anaesthetic management followed a general, balanced technique and the use of invasive monitoring devices. Clotting times were kept within the normal range--prothrombin time between 13 s and 14 s; partial thromboplastin time between 28 s and 30 s. Surgery was straightforward. The patient remained ventilated for 24 h and intravenous morphine (6 micrograms.kg-1.h-1) was used for nurse controlled analgesia. Afterwards, this was changed for patient controlled analgesia. Intravenous heparin was restarted 12 h after surgery and there were no complications postoperatively. Keeping the patient without anticoagulant therapy during this kind of surgery, was the less harmful option, taking into consideration that haemorrhage is inevitable and thromboembolism is a potential, though serious risk.

[Foreign bodies in the tracheobronchial tree. 12 years' experience]. / Corpos estranhos na árvore traqueobrônquica. Experiência de 12 anos.

During a period of twelve years--January 1983 to December 1994, 371 children suspected of foreign body inhalation were admitted in Hospital Pediatric of Coimbra. The diagnosis was confirmed in 200 of them (54%), and this group was analysed. The incidence has increased until 1989 and stabilized in the last 5 years with a median of 18 cases/year. Two third of the children were boys and 84% were under three years old. A history of choking was obtained in 87% of the patients but only 39% of the cases had an early diagnosis (within 24 hours). The most frequent clinical findings were abnormal auscultation, sternal retraction, cough, wheezing and fever. Sixty percent of them were asymptomatic. The chest radiology findings were air trapping in 45%, consolidation in 21% and in 17% there were no abnormalities. Radiopaque foreign bodies were found in 9%. Organic bodies were the most frequent (74%) and among these, peanuts, lupines and beans. Food aspiration in one case took to cardiorespiratory arrest and in another with a late diagnosis bronchial stenosis needed a surgical treatment. Complications of foreign bodies extraction had no consequences.