Fatal cardiac tamponade as a result of a peripherally inserted central venous catheter: a case report and review of the literature.

We present a case of fatal cardiac tamponade that occurred in association with a peripherally inserted central catheter (PICC) inserted from the right antecubital fossa. Migration of the catheter from the right atrium within 24 h of insertion lead to the administration of a potassium-enriched sodium chloride solution into the pericardial space with the development of ST-segment elevation and progression to pulseless electrical activity and, subsequently, ventricular fibrillation. Although signs of tamponade were seen on echocardiography, we propose that myocardial hyperkalaemia from the diffusion of potassium through the epicardium accounted for some of the clinical picture. PICC lines carry a greater risk of migration because of the tip movement associated with arm abduction and, therefore, care must be taken to ensure that the catheter tip is correctly positioned to reduce this risk. When such catheters are used for intra-operative central venous access, we believe chest radiography is mandatory before fluid administration through the catheter, but that this is unnecessary when the catheter is being used solely for central venous pressure monitoring. The use of softer catheters may reduce the risk of vessel perforation. Once tamponade is suspected, all drugs and infusions administered via the catheter should be reviewed, the catheter aspirated and echocardiography performed urgently. This may be facilitated by the greater availability of limited bedside echocardiography within critical care units and theatre complexes.

Intravenous regional analgesia using morphine. The effect on postoperative pain following total knee arthroplasty.

BACKGROUND: We hypothesised that any peripheral action of morphine may contribute to improved postoperative analgesia. The aim of this study was to evaluate the analgesic efficacy of morphine administered preoperatively into an exsanguinated limb prior to total knee arthroplasty. METHODS: A randomised, double-blind, controlled study was performed in 50 patients having total knee arthroplasty surgery. Patients were divided into two groups. In the study group, 0.125 mg/kg morphine in 60 ml of saline was administered intravenously (iv) into the exsanguinated operative limb via a cannula in the foot. A saline intramuscular (im) injection was administered into the opposite leg. The control group received 60 ml saline iv into the operative leg and 0.125 mg/kg morphine im into the opposite leg. Pain was assessed postoperatively using a 10-point visual analogue scale and by comparing morphine requirements and demand:delivery ratios from a patient-controlled analgesic pump. RESULTS: We found no statistically significant difference between the groups in relation to any of the analgesic measures employed. CONCLUSIONS: Intravenous regional analgesia using morphine provides no analgesic advantage over the intramuscular route from 6-24 h postoperatively.

Hepatic rupture complicating eclampsia in pregnancy.

We describe hepatic rupture in a 37-yr-old woman admitted to the intensive care unit after an eclamptic convulsion. The intensive care and surgical management are discussed.

Post dural puncture headache.

We describe the delayed diagnosis and management of a spinal headache following the use of a 24 g Sprotte needle, the results of a survey of spinal needle usage by physicians in the south west of England and a review of the prevention and management of postdural puncture headache.

Transcervical endometrial resection syndrome.

During transcervical endometrial resection the uterine cavity is irrigated under pressure with 1.5% glycine solution. This solution may be absorbed, with consequent fluid and electrolyte shifts. Plasma sodium concentration was analysed in 21 women undergoing transcervical endometrial resection and decreased in every case. In five cases this decrease was > 10 mmol.l-1. Hyponatraemia is a potential risk with this procedure.

Effects of intraarticular morphine on analgesic requirements after anterior cruciate ligament repair.

BACKGROUND AND OBJECTIVES: Intraarticular morphine has been shown to provide postoperative pain relief after knee arthroscopy. The analgesia results from local action within the knee joint. This study was conducted to assess the efficacy of intraarticular morphine as a treatment for postoperative pain after anterior cruciate ligament repair. METHODS: A randomized double blind-study was conducted in patients undergoing elective anterior cruciate ligament repair. Patients in the study group (n = 10) received intraarticularly 5 mg of morphine in a 25 ml dilution. Those in the control group (n = 10) received 25 ml of saline by the same route. Intravenous morphine with patient-controlled analgesia was used in the postoperative period in both the groups. Visual analog scores were recorded at 1, 2, 4, 8, and 24 hours after the operation. The amount of morphine used over the 24-hour postoperative period was documented. RESULTS: The total consumption of morphine over the 24-hour period was significantly lower (p < 0.01) in the study group compared to the control group. The postoperative pain scores were lower in the study group throughout the study period, but this did not reach statistical significance. CONCLUSIONS: Intraarticular morphine reduces analgesic requirements after anterior cruciate ligament repair and is an effective method of providing postoperative analgesia.

Analgesia following arthroscopic knee surgery. A controlled study of intra-articular morphine, bupivacaine or both combined.

In a double-blind, randomised controlled trial, we studied 40 patients who received one of four intra-articular injections at the end of arthroscopic surgery. Each group contained ten patients. The patients in Group 1 received normal saline 25 ml; those in Group 2 received bupivacaine 0.25% 25 ml; those in Group 3 received morphine 5 mg in normal saline 25 ml; and those in Group 4 received a combination of bupivacaine 0.5% 12.5 ml and 5 mg of morphine made up to 25 ml with normal saline to produce the same bupivacaine concentration as Group 2. At the time the patient awoke, and 30min, 1hr, 1hr 30min, 2hr, 4hr, 8hr, 12hr, and 24hr postoperatively, pain was assessed using a visual analogue scale. The need for supplementary analgesic agents in the first 24 hours was recorded. All pain scores were significantly lower (P < 0.05) in Groups 2, 3 and 4 compared with the control group with the exception of Group 2 at 24 hours. Pain scores were significantly lower (P < 0.05) for Group 2 compared with Group 3 for the first 90 minutes postoperatively. At 4, 8, 12 and 24 hours postoperatively the pain scores were significantly lower (P < 0.05%) for Group 3 compared with Group 2. Group 4 had the lowest pain scores over the recorded period compared with the other groups. The need for supplemental analgesia was significantly lower (P < 0.05) in the treatment Groups 2, 3 and 4 compared to the control Group 1. There was no significant difference in supplemental analgesic requirements between Groups 2, 3 and 4.(ABSTRACT TRUNCATED AT 250 WORDS)

Blood transfusion in total hip arthroplasty: guidelines to eliminate overtransfusion.

This study was designed to evaluate the effect of transfusion guidelines on perioperative blood usage with a view to identifying a protocol for transfusion therapy in our hospital. Eighty consecutive patients with normal haemoglobin concentrations presenting for total hip arthroplasty were studied. The maximum allowable blood loss (MABL) was calculated for each patient using the formula of Kallos et al. Blood loss up to this value was replaced with Haemaccel. When the MABL was reached, a haematocrit (Hct) was performed and blood was given if the Hct was less than 30 in men and 27 in women. Otherwise replacement was with Haemaccel. All postoperative complications, duration of hospital stay, and physiotherapy compliance assessments were recorded. A discharge Hct > 36% was the criterion for overtransfusion. The results were compared with findings from a retrospective group before the introduction of these guidelines. Analysis of the data demonstrated a reduction in the frequency of transfusion (97% vs 32% P < 0.05), the volume transfused (2.7 vs 1.3 units P < 0.05), and the incidence of overtransfusion (45% vs 5% P < 0.05) between the two groups of patients. There was no difference between the groups in complication rate, duration of hospital stay or physiotherapy scoring. We conclude that the introduction of guidelines for transfusion in total hip arthroplasty patients has produced a marked reduction in blood usage in our hospital without detrimental effect.

Female circumcision: a risk factor in postpartum haemorrhage.

A major postpartum haemorrhage occurred in a patient with a previous history of female circumcision. Following assisted vaginal delivery 6 litre blood loss occurred as a result of tears to the vagina and perineum. The tears were sutured, followed by insertion of vaginal packs. Replacement fluid therapy was given. To reduce the incidence of tears and accompanying haemorrhage, it is advisable to perform two episiotomies viz. anterior and midline posterior or mediolateral.