Sudden cardiovascular collapse during the TUL procedure: A case series

Although ureteroscopy is a minimally invasive procedure, there have been reports of some minor and major complications, from self-limited to complicated events such as ureteral avulsion, urosepsis, and even death due to cerebrovascular accidents and deep vein thrombosis. Herein, we aim to report seven patients who presented with cardiovascular collapse during ureteroscopy in a 19-year period from January 2002 to January 2021.

Adrenal Crisis During Cesarean Section in a Patient With Primary Adrenal Insufficiency

Congenital adrenal hyperplasia (CAH) is a type of primary adrenal insufficiency (AI) that predisposes to adrenal crisis (AC) during stress. We describe a case of a primipara with CAH who was admitted in labor. To prevent AC, glucocorticoid replacement was given according to guidelines. Due to fetal decelerations, an emergency C-section was performed under general anesthesia following which refractory hypotension emerged. The diagnosis of AC was considered, and hydrocortisone was given with sustained hemodynamic improvement. AC is a life-threatening emergency whose diagnosis requires a high index of suspicion. Despite adequate steroid coverage, additional stressors may precipitate AC, so it is of paramount importance that anesthesiologists consider this emergency.

Cardiovascular Collapse after the Induction of Anesthesia Due to the MASS Effect of Unruptured Giant Bullae

Background and Objectives: Giant bullae rupture easily and cause tension pneumothorax, which can cause problems during general anesthesia. However, the hemodynamic instability that can occur due to the mass effect of an unruptured giant bulla should not be overlooked. Case report: A 43-year-old male patient visited the emergency room with an abdominal wound. There was a giant emphysematous bulla in the left lung. Emergency surgery was decided upon because there was active bleeding according to abdominal CT. After tracheal intubation, the patient's blood pressure and pulse rate dramatically decreased. His blood pressure did not recover despite the use of vasopressors and discontinuation of positive pressure ventilation applied to the lungs. Thus, a bullectomy was immediately performed. The patient's blood pressure and pulse rate were normalized after the bullectomy. Conclusions: If emergency surgery under general anesthesia is required in a patient with a giant emphysematous bulla, it is safe to minimize positive pressure ventilation and remove the giant emphysematous bulla as soon as possible before proceeding with the remainder of the surgery. Tension pneumothorax due to the rupturing of a bulla should be considered first. However, hemodynamic changes might occur due to the mass effect caused by a giant bulla.

An unusual case of neurocardiogenic syncope: A case report and systematic review

We present a case of syncopal episode in emergency department (ED) and subsequent admission to the geriatric assessment unit. The patient presented with self-limiting central abdominal pain. Given a history of previous aortic aneurysm repair, a contrast CT angiogram was performed. With no evidence of leaking aneurysm, the patient was discharged from the ED. The syncopal episode happened while waiting for a taxi. A review of the earlier CT scan showed the presence of air in the venous circulatory system. In hindsight, it was thought the syncopal episode occurred due to air embolism introduced during or shortly after venous cannulation. We discuss the aetiology of venous air embolism and highlight the lack of evidence regarding tolerable amounts of air in the circulatory system. Physiological changes associated with age may suggest that elderly patients are uniquely maladapted to overcome sudden insults to their cardiovascular status.

Peri-intubation Cardiovascular Collapse in Patients Who Are Critically Ill: Insights from the INTUBE Study

Rationale: Cardiovascular instability/collapse is a common peri-intubation event in patients who are critically ill. Objectives: To identify potentially modifiable variables associated with peri-intubation cardiovascular instability/collapse (i.e., systolic arterial pressure <65 mm Hg [once] or <90 mm Hg for >30 minutes; new/increased vasopressor requirement; fluid bolus >15 ml/kg, or cardiac arrest). Methods: INTUBE (International Observational Study to Understand the Impact and Best Practices of Airway Management In Critically Ill Patients) was a multicenter prospective cohort study of patients who were critically ill and undergoing tracheal intubation in a convenience sample of 197 sites from 29 countries across five continents from October 1, 2018, to July 31, 2019. Measurements and Main Results: A total of 2,760 patients were included in this analysis. Peri-intubation cardiovascular instability/collapse occurred in 1,199 out of 2,760 patients (43.4%). Variables associated with this event were older age (odds ratio [OR], 1.02; 95% confidence interval [CI], 1.02-1.03), higher heart rate (OR, 1.008; 95% CI, 1.004-1.012), lower systolic blood pressure (OR, 0.98; 95% CI, 0.98-0.99), lower oxygen saturation as measured by pulse oximetry/Fi_O2 before induction (OR, 0.998; 95% CI, 0.997-0.999), and the use of propofol as an induction agent (OR, 1.28; 95% CI, 1.05-1.57). Patients with peri-intubation cardiovascular instability/collapse were at a higher risk of ICU mortality with an adjusted OR of 2.47 (95% CI, 1.72-3.55), P < 0.001. The inverse probability of treatment weighting method identified the use of propofol as the only factor independently associated with cardiovascular instability/collapse (OR, 1.23; 95% CI, 1.02-1.49). When administered before induction, vasopressors (OR, 1.33; 95% CI, 0.84-2.11) or fluid boluses (OR, 1.17; 95% CI, 0.96-1.44) did not reduce the incidence of cardiovascular instability/collapse. Conclusions: Peri-intubation cardiovascular instability/collapse was associated with an increased risk of both ICU and 28-day mortality. The use of propofol for induction was identified as a modifiable intervention significantly associated with cardiovascular instability/collapse.Clinical trial registered with clinicaltrials.gov (NCT03616054).

Cardiovascular Collapse During Transurethral Resection of Bladder Tumor: A Case Report

Despite innovative modalities, transurethral resection (TUR) procedures are the primary surgical intervention for bladder tumor and enlarged prostate. TUR syndrome, a major complication of TUR procedures, leads to derangement in electrolytes, hemodynamic compromise, and possible cardiac arrest. This case report describes cardiovascular collapse in a 60-year-old male during TUR of a bladder tumor under general anesthesia. The patient developed hypoxia, which progressed to cardiovascular collapse. Electrolyte analysis revealed acute hyponatremia. The patient was resuscitated successfully, transferred to intensive care unit, and discharged from the hospital without any complications. This case report of a cardiovascular collapse during transurethral resection of bladder tumor offers insight of the risks in urologic procedures and highlights the importance of clear communication as well as early recognition and successful management of complications.

Amniotic fluid embolism syndrome: analysis of the Unites States International Registry

BACKGROUND

Incidence, risk factors, and perinatal morbidity and mortality rates related to amniotic fluid embolism remain a challenge to evaluate, given the presence of differing international diagnostic criteria, the lack of a gold standard diagnostic test, and a significant overlap with other causes of obstetric morbidity and mortality.

OBJECTIVE

The aims of this study were (1) to analyze the clinical features and outcomes of women using the largest United States-based contemporary international amniotic fluid embolism registry, and (2) to investigate differences in demographic and obstetric variables, clinical presentation, and outcomes between women with typical versus atypical amniotic fluid embolism, using previously published and validated criteria for the research reporting of amniotic fluid embolism.

MATERIALS AND METHODS

The AFE Registry is an international database established at Baylor College of Medicine (Houston, TX) in partnership with the Amniotic Fluid Embolism Foundation (Vista, CA) and the Perinatology Research Branch of the Division of Intramural Research of the NICHD/NIH/DHHS (Detroit, MI). Charts submitted to the registry between August 2013 and September 2017 were reviewed, and cases were categorized into typical, atypical, non-amniotic fluid embolism, and indeterminate, using the previously published and validated criteria for the research reporting of AFE. Demographic and clinical variables, as well as outcomes for patients with typical and atypical AFE, were recorded and compared. Student t tests, χ2 tests, and analysis of variance tables were used to compare the groups, as appropriate, using SAS/STAT software, version 9.4.

RESULTS

A total of 129 charts were available for review. Of these, 46% (59/129) represented typical amniotic fluid embolism and 12% (15/129) atypical amniotic fluid embolism, 21% (27/129) were non-amniotic fluid embolism cases with a clear alternative diagnosis, and 22% (28/129) had an uncertain diagnosis. Of the 27 women misclassified as an amniotic fluid embolism with an alternative diagnosis, the most common actual diagnosis was hypovolemic shock secondary to postpartum hemorrhage. Ten percent (6/59) of the women with typical amniotic fluid embolism had a pregnancy complicated by placenta previa, and 8% (5/61) had undergone in vitro fertilization to achieve pregnancy. In all, 66% (49/74) of the women with amniotic fluid embolism reported a history of atopy or latex, medication, or food allergy, compared to 34% of the obstetric population delivered at our hospital over the study period (P < .05).

CONCLUSION

Our data represent a series of women with amniotic fluid embolism whose diagnosis has been validated by detailed chart review, using recently published and validated criteria for research reporting of amniotic fluid embolism. Although no definitive risk factors were identified, a high rate of placenta previa, reported allergy, and conceptions achieved through in vitro fertilization was observed.

Successful resuscitation by using extracorporeal membrane oxygenation in a patient with amniotic fluid embolism: a case report

Amniotic fluid embolism (AFE) is a rare disease, but it is a potentially fatal condition, as well as a leading cause of unpredictable maternal death in developed countries. The typical clinical symptoms of AFE include hypoxia, hypotension, and coagulopathy, and with rapid progression, it may cause cardiac arrest and death. We report a case of sudden hemodynamic instability due to amniotic fluid embolism, which was successfully treated with veno-arterial extracorporeal membrane oxygenation (ECMO). A 39-year-old woman was scheduled for delivery at 38 weeks and 2 days of gestation. During labor, sudden generalized tonic-clonic seizures developed, followed by dyspnea and cyanosis. Despite immediate cesarean section being performed, she became hypoxemic and experienced cardiovascular collapse. ECMO was promptly applied, and the patient became stable 8 days after cesarean section. ECMO appears to be an appropriate treatment option for catastrophic amniotic fluid embolism.

Cardiovascular Complications in Patients Undergoing Noncardiac Surgery: A Cardiac Closed Claims Thematic Analysis

More than 200 million adults have noncardiac surgery worldwide every year. Anesthesia closed claims databases allow anesthesia providers to critically examine adverse outcomes that occur during an anesthetic or immediately following the administration of anesthesia, to aid in improving patient care. A qualitative analysis of 34 closed malpractice claims with a cardiac-related event was conducted to determine common themes. Five common themes emerged: preanesthetic evaluation, normalization of deviance, medications, hemorrhage, and knowledge deficit/failed clinical reasoning.

Anaphylactic cardiovascular collapse and Kounis syndrome: systemic vasodilation or coronary vasoconstriction?

The first reported human anaphylactic death is considered to be the Pharaoh Menes death, caused by a wasp sting. Currently, anaphylactic cardiovascular events represent one of most frequent medical emergencies. Rapid diagnosis, prompt and appropriate treatment can be life saving. The main concept beyond anaphylaxis lies to myocardial damage and ventricular dysfunction, thus resulting in cardiovascular collapse. Cardiac output depression due to coronary hypoperfusion from systemic vasodilation, leakage of plasma and volume loss due to increased vascular permeability, as well as reduced venous return, are regarded as the main causes of cardiovascular collapse. Clinical reports and experiments indicate that the human heart, in general, and the coronary arteries, in particular, could be the primary target of the released anaphylactic mediators. Coronary vasoconstriction and thrombosis induced by the released mediators namely histamine, chymase, tryptase, cathepsin D, leukotrienes, thromboxane and platelet activating factor (PAF) can result to further myocardial damage and anaphylaxis associated acute coronary syndrome, the so-called Kounis syndrome. Kounis syndrome with increase of cardiac troponin and other cardiac biomarkers, can progress to heart failure and cardiovascular collapse. In experimental anaphylaxis, cardiac reactions caused by the intracardiac histamine and release of other anaphylactic mediators are followed by secondary cardiovascular reactions, such as cardiac arrhythmias, atrioventricular block, acute myocardial ischemia, decrease in coronary blood flow and cardiac output, cerebral blood flow, left ventricular developed pressure (LVdp/dtmax) as well as increase in portal venous and coronary vascular resistance denoting vascular spasm. Clinically, some patients with anaphylactic myocardial infarction respond satisfactorily to appropriate interventional and medical therapy, while anti-allergic treatment with antihistamines, corticosteroids and fluid replacement might be ineffective. Therefore, differentiating the decrease of cardiac output due to myocardial tissue hypoperfusion from systemic vasodilation and leakage of plasma, from myocardial tissue due to coronary vasoconstriction and thrombosis might be challenging during anaphylactic cardiac collapse. Combined antiallergic, anti-ischemic and antithrombotic treatment seems currently beneficial. Simultaneous measurements of peripheral arterial resistance and coronary blood flow with newer diagnostic techniques including cardiac magnetic resonance imaging (MRI) and myocardial scintigraphy may help elucidating the pathophysiology of anaphylactic cardiovascular collapse, thus rendering treatment more rapid and effective.

Propranolol-Induced Circulatory Collapse in a Patient With Thyroid Crisis and Underlying Thyrocardiac Disease: A Word of Caution

Thyrotoxic crisis or thyroid storm is a severe form of hyperthyroidism and a rare endocrinological emergency. The cornerstones of medical therapy in thyroid storm include decreasing the levels of circulating T3 in the blood as well as inhibiting the hormone's peripheral effects through β-adrenergic blockade. Propranolol is the preferred agent for β-blockade in hyperthyroidism and thyroid storm due to its additional effect of blocking the peripheral conversion of inactive T4 to active form T3. We report a typical clinical scenario where propranolol was administered in treatment of thyroid storm but an uncommon adverse outcome: circulatory failure from cardiogenic shock warranting vasopressor and inotropic support. Caution with regard to the use long-acting β-blocking agents in patients with underling thyrocardiac disease may prevent this life-threatening adverse effect. Ultra-short-acting β-blockers that are easy to titrate maybe a suitable alternative in this subset of patients.

Amniotic Fluid Embolism. Is a New Pregnancy Possible? Case Report

Amniotic fluid embolism (AFE) is a rare but potentially catastrophic clinical condition, characterized by a combination of signs and symptoms that reflect respiratory distress, cardiovascular collapse and disseminated intravascular coagulation (DIC). Its pathogenesis is still unclear. More recently, the traditional view of obstruction of pulmonary capillary vessels by amniotic fluid emboli as the main explanation for the etiology has been ruled out, and immunologic factors and the activation of the inflammatory cascade took on an important role. Amniotic fluid embolism has an unpredictable character, its diagnosis is exclusively clinical, and the treatment consists mainly of cardiovascular support and administration of blood products to correct the DIC. No diagnostic test is recommended until now, though multiple blood markers are currently being studied. The authors present a case report of a woman who had survived AFE in her previous pregnancy and had a subsequent pregnancy without recurrence, providing one more clinical testimony of the low risks for the pregnancy after AFE.

Mitochondrial N-formyl peptides induce cardiovascular collapse and sepsis-like syndrome

Fifty percent of trauma patients who present sepsis-like syndrome do not have bacterial infections. This condition is known as systemic inflammatory response syndrome (SIRS). A unifying factor of SIRS and sepsis is cardiovascular collapse. Trauma and severe blood loss cause the release of endogenous molecules known as damage-associated molecular patterns. Mitochondrial N-formyl peptides (F-MIT) are damage-associated molecular patterns that share similarities with bacterial N-formylated peptides and are potent immune system activators. The goal of this study was to investigate whether F-MIT trigger SIRS, including hypotension and vascular collapse via formyl peptide receptor (FPR) activation. We evaluated cardiovascular parameters in Wistar rats treated with FPR or histamine receptor antagonists and inhibitors of the nitric oxide pathway before and after F-MIT infusion. F-MIT, but not nonformylated peptides or mitochondrial DNA, induced severe hypotension via FPR activation and nitric oxide and histamine release. Moreover, F-MIT infusion induced hyperthermia, blood clotting, and increased vascular permeability. To evaluate the role of leukocytes in F-MIT-induced hypotension, neutrophil, basophil, or mast cells were depleted. Depletion of basophils, but not neutrophils or mast cells, abolished F-MIT-induced hypotension. Rats that underwent hemorrhagic shock increased plasma levels of mitochondrial formylated proteins associated with lung damage and antagonism of FPR ameliorated hemorrhagic shock-induced lung injury. Finally, F-MIT induced vasodilatation in isolated resistance arteries via FPR activation; however, F-MIT impaired endothelium-dependent relaxation in the presence of blood. These data suggest that F-MIT may be the link among trauma, SIRS, and cardiovascular collapse.

Use of an impedance threshold device to treat severe hypotension in a pregnant woman: case report and review of the literature

BACKGROUND

Impedance threshold device technology harnesses the patient's normal physiological mechanisms to increase circulation during hypotensive crises. We report the first clinical use of one version of this device on a spontaneously breathing hypotensive pregnant woman.

OBJECTIVE

The objective of our study was to report this case to help Emergency Medical Service rescue personnel to noninvasively treat hypotensive but conscious spontaneously breathing patients.

CASE REPORT

A 28-year-old woman who was 21 weeks pregnant developed frank syncope at home but recovered spontaneously. When Emergency Medical Service paramedics arrived, her initial blood pressure and heart rate were 115/80 mm Hg and 125 beats/min, respectively. She suddenly complained of feeling anxious and developed profound bradycardia and hypotension, followed by 20 s of asystole. An impedance threshold device (ResQGARD™) with -7 cmH2O resistance to inspiration was rapidly applied using a facemask. After four spontaneous breaths, blood pressure increased from 62/40 mm Hg to 106/66 mm Hg. She was hemodynamically stable thereafter.

CONCLUSIONS

In this case report, the multiple physiological effects of inspiration through -7 cmH2O resistance helped this pregnant hypotensive patient to rapidly and noninvasively restore adequate perfusion and reduced the duration of her hypotensive episode. To our knowledge, this is the first report of this technology in a pregnant hypotensive but spontaneously breathing patient.

A review of local anesthetic cardiotoxicity and treatment with lipid emulsion

Cardiovascular collapse from accidental local anesthetic toxicity is a rare but catastrophic complication of regional anesthesia. The long-acting amide local anesthetics bupivacaine, levobupivacaine and ropivacaine have differential cardiac toxicity, but all are capable of causing death with accidental overdose. In recent times, the chance discovery that lipid emulsion may improve the chance of successful resuscitation has lead to recommendations that it should be available in every location where regional anesthesia is performed. This review will outline the mechanisms of local anesthetic toxicity and the rationale for lipid emulsion therapy.

Amniotic fluid embolism: an evidence-based review

We conducted an evidence-based review of information about [corrected] amniotic fluid embolism (AFE). The estimated incidence of AFE is 1:15,200 and 1:53,800 deliveries in North America and Europe, respectively. The case fatality rate and perinatal mortality associated with AFE are 13-30% and 9-44%, respectively. Risk factors associated with an [corrected] increased risk of AFE include advanced maternal age, placental abnormalities, operative deliveries, eclampsia, polyhydramnios, cervical lacerations, [corrected] and uterine rupture. The hemodynamic response in [corrected] AFE is biphasic, with initial pulmonary hypertension and right ventricular failure, followed by left ventricular failure. Promising therapies include selective pulmonary vasodilators and recombinant activated factor VIIa. Important topics for future research are presented.

Two cases of systemic capillary leak syndrome that were treated with pentastarch

Systemic capillary leak syndrome (SCLS) is a condition that's caused by the shift of fluid and protein from the intravascular space to the interstitial space as a result of repetitive episodes of capillary hyperpermeability. The pathogenesis of SCLS is still unclear, but there's recently been a report showing this syndrome in association with monoclonal gammopathy. This syndrome can be a fatal disease because cardiovascular collapse can occur in the initial capillary leak phase. Although theophylline, diuretics, terbutaline, steroids, calcium antagonist, Ginkgo biloba extracts and plasmapheresis have been suggested as medication, none of them have been proven to be effective. Considering that this disease is self-limiting, conservative treatment in the acute phase is believed to be very important. Because hypoalbuminemia is very a common manifestation of SCLS, Pentastarch, which has a higher molecular weight than albumin, could be efficient to prevent cardiovascular collapse. We used 10% Pentastarch during the acute SCLS attacks of 2 patients and the patients both showed a dramatic response. Pentastarch may be helpful to treat SCLS in its initial capillary leak phase by the elevating blood pressure, and this might contribute to somewhat decreasing the acute mortality of SCLS.