A serious anaesthetic complication of a Lefort I osteotomy.

We report a case of surgical transsection of the nasoendotracheal tube during a Lefort I maxillary osteotomy, resulting in severe intra-operative ventilatory difficulties. The management of this problem and a brief review of the literature are presented.

Bilateral mydriasis during laparoscopic surgery.

Peritoneal insufflation with CO2 has been associated with profound cardiorespiratory disturbances, which may modify cerebral blood flow (CBF), particularly in hypertensive patients in whom CBF autoregulation is altered. We report a case of bilateral mydriasis during laparoscopic gastrectomy in a patient with chronic hypertension followed by a coma lasting several hours and we shortly discuss the possible mechanisms involved.

Hemodynamic changes during laparoscopic gastroplasty in morbidly obese patients.

BACKGROUND: In nonobese patients, peritoneal insufflation has consistently been shown to influence parameters of preload and afterload as well as cardiac output. Obese patients have an abnormal and particular cardiovascular status. The aim of this study was to investigate the hemodynamic changes induced by an increase of intra-abdominal pressure in morbidly obese patients (MOP). METHODS: Standard general anesthesia was administered to 15 informed MOP (body mass index > 40 kg/m2) scheduled for laparoscopic gastroplasty. Hemodynamic parameters were measured by thermodilution through a pulmonary artery catheter and through invasive blood pressure monitoring. RESULTS: CO2 insufflation with an intra-abdominal pressure of 17 mmHg caused a significant increase of mean arterial pressure (MAP) (33%, P = 0.005), mean pulmonary arterial pressure (MPAP) (40%, P = 0.001), pulmonary capillary wedge pressure (PCWP) (41%, P = 0.001), and central venous pressure (CVP) (55%, P = 0.001). The increase in diastolic filling pressures could be due to an increase in the filling volume or to a decrease in diastolic compliance. Ventricular volumes were not measured but we speculate that the rise in CVP, PCWP and MPAP is due to an increase in intrathoracic pressure as judged by the increase of pulmonary airway pressure. Stroke volume fell slightly (11%, P = 0.008), because of a reduction in transmural pressure and a fall in effective preload. Cardiac output rose slightly (16%, P = 0.005) because of an increase in heart rate (15%, P = 0.014) probably induced by sympathetic stimulation, which only became fully operative after 15 minutes. CONCLUSIONS: When compared to nonobese patients our obese patients tolerated the pneumoperitoneum surprisingly well, without experiencing fall in cardiac output. The hemodynamic consequences of peritoneal insufflation seem to be different in obese and nonobese patients.

Changes in pulmonary mechanics during laparoscopic gastroplasty in morbidly obese patients.

BACKGROUND: Obesity is an important respiratory risk factor after abdominal surgery. Laparoscopic surgical techniques seem beneficial in obese patients in terms of respiratory morbidity, with a faster return to normal respiratory function. However, there is little information about intraoperative respiratory mechanics and about patient tolerance to abdominal insufflation in the morbidly obese. METHODS: We studied respiratory mechanics and arterial blood gases in 15 morbidly obese patients (mean BMI = 45) undergoing laparoscopic gastroplasty under general anaesthesia and controlled ventilation. Respiratory mechanics were analysed using side-stream spirometry. RESULTS: When compared to preinsufflation values, servocontrolled abdominal insufflation to 2.26 kPa caused a significant decrease in respiratory system compliance (31%), a significant increase in peak (17%) and plateau (32%) airway pressures at constant tidal volume with a significant hypercapnia but no change in arterial O2 saturation. Respiratory system compliance and pulmonary insufflation pressures returned to baseline values after abdominal deflation. CONCLUSION: These alterations in pulmonary mechanics are less than those observed with comparable degrees of abdominal inflation in non-obese patients, and were well tolerated. From the point of view of intraoperative respiratory mechanics, laparoscopic surgery is safe in morbidly obese patients.

[Biliary ileus]. / Ileus biliaire.

A case of gallstone ileus in an elderly woman is described and attention is drawn to the insidious clinical presentation and the significance of the often subtle radiological signs. The data from the literature specifies these aspects and allows a more complete review of this relatively rare pathology in order to remind its importance in differential diagnosis to emergency clinicians and radiologists.

Transient radicular irritation followed by meningitis after spinal anesthesia.

Neurotoxicity of spinally administered hyperbaric 5% lidocaine is becoming a serious concern in view of the recent literature. We report a case of probable neurotoxicity of hyperbaric 5% lidocaine, followed by an aseptic meningitis. This case report emphasizes the danger of using hyperbaric 5% lidocaine in a too high dose while performing spinal anesthesia.

Methaemoglobinemia induced by a low dose of prilocaïne during interscalenic block.

Methaemoglobinemia is a rare but well known complication of the use of prilocaïne in locoregional anaesthesia. We report a case of methaemoglobinemia following the administration of a low dose of prilocaïne for an interscalenic bloc. We suggest some hypotheses to explain this phenomenon. This case illustrates the necessity of pulse oximetry monitoring in all patients receiving prilocaïne during locoregional anaesthesia.