Early Massive Pulmonary Embolism After Total Hip Arthroplasty in a Patient With Behcet Disease: A Case Report.

Venous complications in Behcet disease (BD) affect nearly 40% of patients. We describe a woman with BD who presented with a massive bilateral pulmonary embolism 30 hours after total hip arthroplasty. The patient underwent surgical thrombectomy and venoarterial extracorporeal membrane oxygenation. Methotrexate was withheld 15 days before surgery and restarted on postoperative day 2. Immunosuppressive therapy, such as methotrexate, appears to be the most effective prophylactic treatment for venous thrombosis in patients with BD, whereas prophylaxis with low-molecular-weight heparin may be ineffective, as was the situation in our patient. Therefore, continuation of methotrexate perioperatively should be considered in patients with BD. Systematically performing preoperative deep vein thrombosis screening should be also considered. The patient also had diabetes mellitus treated with metformin and sitagliptin preoperatively.

Prediction of Delayed Cerebral Ischemia After Subarachnoid Hemorrhage Using Cerebral Blood Flow Velocities and Cerebral Autoregulation Assessment.

BACKGROUND: The risk of delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH) is associated with large cerebral artery vasospasm, but vasospasm is not a strong predictor for DCI. Assessment of cerebral autoregulation with transcranial Doppler (TCD) may improve the prediction of DCI. The aim of this prospective study was to assess the value of TCD-derived variables to be used alone or in combination for prediction of DCI. METHODS: We included consecutive patients with low-grade aneurysmal SAH within 4 days of aneurysm rupture. Cerebral autoregulation was evaluated using the moving correlation coefficient Mx calculated from spontaneous fluctuations of cerebral blood flow velocities and arterial blood pressure. Transcranial color-coded sonography was performed to assess large artery vasospasm. RESULTS: Thirty patients (19 women and 11 men; mean age ± SD 44.7 ± 12.1 years) were included. Twenty (66.7%) patients had vasospasm. DCI occurred in six (20%) patients after a median delay of 10 days (range 8-13 days). Cerebral autoregulation was impaired at baseline and at day 7 and then returned to normal at day 14. Neither cerebral autoregulation impairment nor large artery vasospasm alone was associated with DCI. In contrast, the combination of large artery vasospasm with worsening impairment of cerebral autoregulation from baseline to day 7 was significantly correlated to subsequent DCI (p = 0.007). CONCLUSIONS: Early deterioration of cerebral autoregulation was strongly predictive of DCI in patients with large artery vasospasm after low-grade SAH. Our results suggest that consideration to both cerebral blood flow velocities and cerebral autoregulation may improve the prediction of DCI.

The effects of spinal anesthesia on cerebral blood flow in the very elderly.

BACKGROUND: Aging and disease may make elderly patients particularly susceptible to hypotension during spinal anesthesia. However, the impact of small-dose bupivacaine on cerebral hemodynamics is not known. In this study, we assessed the effects of spinal anesthesia on cerebral blood flow (CBF) in very elderly patients. METHODS: We prospectively studied 20 patients aged >75 yr who underwent open surgical repair of a hip fracture and compared them with a control group of patients younger than 60 yr. Patients were placed in the lateral decubitus position to receive spinal anesthesia at L4-5 level. Noninvasive automated arterial blood pressure, heart rate, and transcranial Doppler measurements were recorded before spinal anesthesia (baseline = T0), 5 min after the end of local anesthetic injection (T1), 10 min after spinal anesthesia (T2), and in the postanesthesia care unit (T3). RESULTS: Systolic blood pressure significantly decreased at T1 (115 +/- 25 mm Hg) and T2 (114 +/- 24 mm Hg) compared with T0 (136 +/- 21 mm Hg) in the elderly group. Systolic and diastolic velocities significantly decreased compared to baseline values (at T1, T2). Significant modifications of the pulsatility index (PI) and resistance index occurred at T2 for PI and resistance index. No patient experienced an episode of bradycardia. Heart rate variations were not significantly different compared to T0. Neither hemodynamics nor cerebral effects were observed in the control group. CONCLUSION: In summary, spinal anesthesia results in a very small but statistically significant reduction of CBF velocity in very elderly patients.