Anaphylactic shock in a beta-blocked child: usefulness of isoproterenol.

Like adults, children taking beta-blockers are at risk for serious hemodynamic instability in case of anaphylaxis. We report a case of severe bradycardia associated with anaphylactic shock after aprotinin in a beta-blocked child, which was resistant to intravenous epinephrine and vascular filling but was treated successfully with isoproterenol

Intra- and postoperative factors determining neurological complications after surgery under deep hypothermic circulatory arrest: a retrospective somatosensory evoked potential study

Objectives: Intraoperative median nerve SEP monitoring uses the disappearance of cortical and brain stem activities as the criterion to determine that brain cooling is sufficient in deep hypothermic circulatory arrest (CA) surgery. This study presents the results of a retrospective SEP analysis of intraoperative events that engendered neurological complications. Methods: Median nerve SEP monitoring was performed on 58 consecutive patients who underwent surgery under deep hypothermic CA. The monitoring was retrospectively analyzed and compared with intraoperative events, and postoperative symptoms. Results: Intraoperative SEP abnormalities were observed in 9 out of the 16 patients who presented neurological complications. Among the 7 others, the abnormalities either were present preoperatively (n = 2), occurred postoperatively (n = 3) or only involved the lower limbs (n = 2). Although the mere inspection of the intraoperative SEPs was insufficient to determine the origin of the alterations, their comparison with intraoperative events facilitated the identification of hemodynamic factors in 7 cases and embolism in two cases. There were no patients in whom CA per se caused neurological complications. Conclusions: Intraoperative SEP monitoring helps identify intraoperative events responsible for neurological complications and prevent these in subsequent procedures. However, the neurological complications of deep hypothermic CA can also be due to pre- or postoperative factors that escape the domain of intraoperative monitoring. (C) 2000 Elsevier Science ireland Ltd. All rights reserved

Reprises de sternotomie médiane après chirurgie cardiaque en 1988: étude rétrospective

[Revision of Midline Sternotomies After Cardiac-surgery in 1988 - Retrospective Study] Twenty-three of 514 (4.6%) patients who underwent cardiac surgery in 1988 with cardiopulmonary bypass were later reoperated for sternal complications. Several risk factors, including pre-, intra and postoperative variables, have been investigated. A significant correlation was found with the presence of diabetes mellitus, the type of operation (bilateral internal mammary artery grafting), early reoperations, haemodynamic alterations, pulmonary infections and incidence of serious non infectious complications. The different sternal complications are analyzed from a clinical and therapeutic point of view

The usefulness of the spinal and subcortical components of the posterior tibial nerve SEPs for spinal cord monitoring during aortic coarctation repair

This study examines how the recording of the lumbar and subcortical components of the posterior tibial nerve (PTN) SEPs may usefully replace that of cortical components in situations in which these components cannot be reliably obtained (infants, high concentrations of halogenated gasses). Lumbar, brain-stem, and cortical PTN SEPs were intraoperatively monitored in 7 patients undergoing repair of aortic coarctation under variable isoflurane concentration (up to 1.2%). Four patients were less than 1 year old. Two distinct activities were evidenced at the lumbar level in all of the patients: the dorsal root component (DRC) and the dorsal horn negativity (DHN). The equivalent of the adult P30 (lemniscal positivity; LP) was also present in all of the patients, whatever their age or the concentration of isoflurane. By contrast, the parietal activities were absent intraoperatively in the youngest patients. Spinal-cord ischemia consecutive to aortic cross-clamping gave rise to early DHN changes and later alterations of the LP in the two patients in which it occurred, while the DRC and the peripheral nerve activities remained unchanged. This elective sensitivity of the DHN is likely due to it being dependent on the gray matter of the spinal cord, the basal metabolism of which is greater than that of the white matter and to the situation of the DHN generator in a watershed zone of the spinal cord. This study emphasizes the interest of PTN SEPs for spinal-cord monitoring in vascular surgery and the importance of combining the recording of parietal activities with that of the lumbar spinal components

Surgical angioplasty of the left main coronary artery.

The conventional surgical treatment of isolated critical stenosis of the left main coronary artery restores a less physiologic perfusion of the myocardium, leads to occlusion of the left coronary ostium, and consumes an appreciable length of bypass material. Starting in June 1985, 23 surgical angioplasties have been performed in 22 patients. The left main stem was approached posteriorly in the first 11 patients, and an anterior approach was preferred in the last 12 because of better exposure. The onlay patch consisted of saphenous vein in the first 14 patients; pericardium was preferred in the last nine. The five failures occurred early. Four of these occurred in patients older than 60 years in whom calcifications of the left main stem had been seen on the preoperative angiogram. Eighteen procedures (78.3%) succeeded, but one patient (5.5%) died later of a massive air embolism. The 17 survivors are free of symptoms (maximal stress test combined with thallium scintigraphy) after a mean follow-up of 24.3 months. Angiographic restudy at an average of 8 months was obtained in 14 patients (82.3%) and revealed an excellent result in 13. In five patients, a late angiographic restudy (22 to 37 months) still revealed perfect patency of the left main stem. Provided that well-defined contraindications (calcifications, involvement of the distal bifurcation, older age) are respected, surgical angioplasty deserves a place in the array of surgical strategies