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Cited by 8 publications
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Case reportIn 1987, a 27-yr-old healthy woman presented for an elective Caesarean section. She had had a previous Caesarean section under general anaesthesia without difficulty. There were no problems found on history or physical examination. The patient decided after discussion with her general practitioner and anaesthetist to have an epidural an- Accepted for publication 25th June, 1993. aesthetic for pain control. Haemoglobin and urinalysis were normal. She was given 30 ml Na citrate outside the OR.At 08:00 a continuous epidural catheter was inserted with the patient in the seated position with no difficulty. The patient was positioned with a wedge under her right hip. Intermittent injections to a total of 22 ml lidocaine 2% with epinephrine were placed in the epidural space. One litre of normal saline was given /v. The monitors were a hard copy blood pressure (BP) showing normal fluctuating BP and pulse and an ECG. The epidural level was tested and found to be at the T~_ 6 level. Surgery started 20 min after the epidural was inserted. The patient was carrying on a normal social conversation.At 08:45 (as the head of a normal crying infant was delivered through the anterior abdominal wall) the mother suddenly complained of shortness of breath (SOB), began to hyperventilate, coughed and became cyanosed. The blood pressure decreased, the sinus heart rate increased, and she may have suffered a seizure (there was thrashing of both arms). Almost immediately BP and pulse on the Dinemapp recorder were undetectable (Table I -8:48) but the ECG showed sinus tachycardia. The airway was managed initially with mask and oxygen and then the trachea was intubated without difficulty. Breathing was managed initially with mask ventilation with oxygen and continued with bag ventilation through the endotracheal tube. There was no bronchospasm and air entry was equal bilaterally.Circulation was managed by the infusion of fluid, drugs which included ephedrine, epinephrine, NaHCO3, isuprel and atropine, and cardiac massage. Other drugs given included Na citrate preoperatively, succinylcholine, atracurium, thiopentone, and oxytocin. At various times another anaesthetist, two intensive care physicians and nurses were in the operating room observing and helping with the resuscitation. These manoeuvres were successful in returning blood pressure but the patient remained cyanosed in spite of an adequate blood pressure and positive pressure ventilation with 100% 02.The blood pressure decreased a second time (Table I -9:01) and again the patient was resuscitated. The fwst inadequate blood pressure (taken from the Dinemapp) was recorded at 08:48 (only one reading at this level). The total time between adequate blood pressures was seven minutes. The total time of inadequate blood CAN J ANAESTH 1993 / 40:I0 / pp 971-80
Case reportIn 1987, a 27-yr-old healthy woman presented for an elective Caesarean section. She had had a previous Caesarean section under general anaesthesia without difficulty. There were no problems found on history or physical examination. The patient decided after discussion with her general practitioner and anaesthetist to have an epidural an- Accepted for publication 25th June, 1993. aesthetic for pain control. Haemoglobin and urinalysis were normal. She was given 30 ml Na citrate outside the OR.At 08:00 a continuous epidural catheter was inserted with the patient in the seated position with no difficulty. The patient was positioned with a wedge under her right hip. Intermittent injections to a total of 22 ml lidocaine 2% with epinephrine were placed in the epidural space. One litre of normal saline was given /v. The monitors were a hard copy blood pressure (BP) showing normal fluctuating BP and pulse and an ECG. The epidural level was tested and found to be at the T~_ 6 level. Surgery started 20 min after the epidural was inserted. The patient was carrying on a normal social conversation.At 08:45 (as the head of a normal crying infant was delivered through the anterior abdominal wall) the mother suddenly complained of shortness of breath (SOB), began to hyperventilate, coughed and became cyanosed. The blood pressure decreased, the sinus heart rate increased, and she may have suffered a seizure (there was thrashing of both arms). Almost immediately BP and pulse on the Dinemapp recorder were undetectable (Table I -8:48) but the ECG showed sinus tachycardia. The airway was managed initially with mask and oxygen and then the trachea was intubated without difficulty. Breathing was managed initially with mask ventilation with oxygen and continued with bag ventilation through the endotracheal tube. There was no bronchospasm and air entry was equal bilaterally.Circulation was managed by the infusion of fluid, drugs which included ephedrine, epinephrine, NaHCO3, isuprel and atropine, and cardiac massage. Other drugs given included Na citrate preoperatively, succinylcholine, atracurium, thiopentone, and oxytocin. At various times another anaesthetist, two intensive care physicians and nurses were in the operating room observing and helping with the resuscitation. These manoeuvres were successful in returning blood pressure but the patient remained cyanosed in spite of an adequate blood pressure and positive pressure ventilation with 100% 02.The blood pressure decreased a second time (Table I -9:01) and again the patient was resuscitated. The fwst inadequate blood pressure (taken from the Dinemapp) was recorded at 08:48 (only one reading at this level). The total time between adequate blood pressures was seven minutes. The total time of inadequate blood CAN J ANAESTH 1993 / 40:I0 / pp 971-80
Peripartum cardiomyopathy (PPCM) is defined as the development of heart failure in the last trimester of pregnancy or up to the sixth postpartum month. There is absence of demonstrable heart disease prior to the last trimester and no aetiology can be found.l'2The major concerns in a patient with PPCM during Caesarean section are to optimise fluid administration and to avoid factors which may cause myocardial depression. Appropriate haemodynamic monitors shoutd be employed and chosen according to the clinical condition of each patient. Our criteria for selecting a non-invasive monitoring technique arc described in the following Case Report.
88Purpose: To review the literature since 1979 to determine the natural history, etiology, diagnosis and potential treatment of amniotic fluid embolus (AFE).Source: English language articles and books published between June 1976 and June 1998 were identified by a computerized medline search using the title or text word amniotic fluid embolus. This same search strategy was repeated and updated to October 1999 by an independent individual using both Medline and Embase. The search was also expanded to include Science Citation Index listing Morgan's 1979 review article. All relevant publications were retrieved and their bibliographies were scanned for additional sources.Principal findings: Randomized controlled trials are not possible with amniotic fluid emboli. The majority of the literature consists of clinical reports combined with occasional limited reviews. Knowledge obtained from these reports suggests that amniotic fluid emboli present as a spectrum of disease that ranges from a subclinical entity to one that is rapidly fatal. Because cases are sporadic and the diagnosis is often unconfirmed, little progress has been made towards understanding its etiology or defining the risk factors. Present management is empirical and directed towards the maintenance of oxygenation, circulatory support and the correction of coagulopathy.Conclusion: Amniotic fluid embolus continues to be a life-threatening but potentially reversible complication unique to pregnancy. It cannot be predicted nor prevented. Review of the literature reveals that there are no standardized investigational methods or protocols to confirm the diagnosis in suspected cases.Objectif : Passer en revue la littérature depuis 1979 pour déterminer l'histoire naturelle, l'étiologie, le diagnostic et le traitement potentiel d'une embolie amniotique (EA).Source : Des articles et des livres de langue anglaise, publiés entre juin 1976 et juin 1998, ont été sélectionnés lors d'une recherche informatisée de données médicales en utilisant les titres ou l'expression amniotic fluid embolus. La même méthode de recherche a été utilisée par un individu indépendant pour obtenir une mise à jour jusqu'en octobre 1999 avec Medline et Embase. La recherche a été étendue au Science Citation Index qui présentait la revue de Morgan de 1979. Tous les articles pertinents ont été retenus et leurs bibliographies examinées pour découvrir des sources supplémentaires.Constatations principales : Les essais contrôlés et randomisés sur l'embolie amniotique sont impossibles. La plus grande partie de la documentation constituée de résumés cliniques combinés à des revues limitées occasionnelles. Les connaissances dégagées de ces résumés suggèrent que l'embolie amniotique se présente comme de multiples affections allant de l'entité subclinique à la maladie rapidement fatale. Les cas étant rares et le diagnostic souvent non confirmé, peu de progrès ont été réalisés pour mieux en comprendre les causes ou pour définir ses facteurs de risque. Le traitement actuel est empirique et vise à maintenir...
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