Cardiac Arrest during Transesophageal Echocardiogram (TEE) due to Acute Right Ventricular Failure

The case of a patient who suffered cardiac arrest while undergoing transesophageal echocardiography (TEE) is presented here. A 75-year-old man with moderate right ventricular (RV) dysfunction and pulmonary hypertension became bradycardic and hypotensive after receiving propofol for procedural sedation. His profound hypotension ultimately led to a pulseless electrical activity (PEA) cardiac arrest. TEE images captured immediately prior to cardiac arrest show a severely dilated and hypokinetic RV, consistent with acute right ventricular failure. This case highlights the potentially fatal consequences of procedural sedation in patients with RV dysfunction and pulmonary hypertension.

Atypical presentation of catastophric spontaneous mesenteric bleeding

Spontaneous mesenteric bleeding is an exceptionally rare clinical condition and potentially lethal especially among elderly patients who are taking oral anticoagulant. We present a case of a 79-year-old woman who presented to the emergency department with atypical chest pain which was radiating to the back. She developed profound hypotension with a sudden drop of haemoglobin. Contrast-enhanced CT of the aorta showed active mesenteric bleeding with mesenteric haematoma. The early diagnosis relies solely on a high index of suspicion of occult bleeding in patients with unexplained hypotension with a sudden drop of haemoglobin. Troponin can be falsely positive in mesenteric bleeding. Close monitoring to detect any sign of deterioration and early imaging in diagnosing intra-abdominal bleeding can help to avoid delay in treatment which is essential to prevent mortality and morbidity.

Use of Remdesivir in The Treatment of COVID-19 Infection Among Sudanese Patients - Case Series

Introduction: COVID-19 infection is a viral pandemic started in 2019, all societies have the susceptibility of getting infected. Remdesivir is an anti-retroviral agent, with a broad spectrum of activity. Remdesivir activity against COVID-19 had been studied in both in vitro and in vivo, but still considered new for COVID-19 treatment and not available in all countries. The aim of our study was to report the use of remdesivir among Sudanese population and report the adverse events related to the course of treatment. Methods: case series study was conducted in Imperial Hospital reporting the three cases who received Remdesivir for treating COVID-19 infection.Cases presentation: Three cases had received remdesivir for treating COVID-19 infection, side effects reported were elevated liver enzymes, profound hypotension and hypoalbuminemia. Discussion: All three patients were severe cases of COVID-19 admitted to the ICU. Unexpectedly, severe resistant hypotension was the cause of death in 2 cases who received remdesivir. Increased liver enzymes was noticed in one case. In the other hand, hypoalbuminemia was noticed in one case as well.

Profound Hypotension before Aortic Clamping Can Exacerbate Spinal Cord Ischemic Injury after Aortic Surgery in Rats

Spinal cord ischemia is one of the most serious complications of aortic repair in patients with acute aortic syndrome. However, the effect of hypotension before aortic clamping on spinal cord injury has not been documented. A total of 48 male Sprague-Dawley rats were randomly divided into four groups: the sham group; control group (mean arterial pressure (MAP) < 90% of baseline value before aortic clamping); mild hypotension group (MAP < 80%); and profound hypotension group (MAP < 60%). Spinal cord ischemia was induced using a balloon-tipped catheter placed in the descending thoracic aorta. Neurological function of the hind limbs was evaluated for seven days after reperfusion and recorded using a motor deficit index (MDI). The spinal cord was then harvested for histopathological examination and evaluation of oxidative stress and inflammation. The profound hypotension group demonstrated a significantly higher MDI 48 h post-reperfusion and lower number of normal motor neurons than the other groups (p < 0.001). The levels of tissue malondialdehyde and tumor necrosis factor-α (TNF-α) were also significantly increased in the profound hypotension group compared with other groups. Profound hypotension before aortic clamping can aggravate neurologic outcomes after aortic surgery by exacerbating neurologic injury and reducing the number of normal motor neurons.

Anaphylaxis induced by sugammadex and sugammadex-rocuronium complex -a case report-

Background: In sugammadex-induced anaphylaxis, sugammadex and/or sugammadex-rocuronium complex have possible allergenic epitope. Case: We report a case of sugammadex-induced anaphylaxis during general anesthesia in a 60-year-old male undergoing orthopedic hand surgery, manifesting as profound hypotension and urticaria. The timing of onset was closely associated with sugammadex administration. The patient recovered after extensive therapy including fluid, epinephrine, other vasopressors, steroid, and antihistamine administration. By intradermal skin test which was done at four weeks after anaphylaxis, we confirmed positive reactions to both sugammadex and sugammadex-rocuronium complex. Conclusions: This is a rare case of sugammadex-induced anaphylaxis that both sugammadex and sugammadex-rocuronium complex were confirmed as allergenic epitopes.

Refractory Unforeseen Anaphylaxis Case in a Rural OR Unit

A 35-year-old female patient with no previously documented allergies who was admitted for elective gynaecological surgery, developed rapid onset, severe anaphylaxis, with dyspnea and cardiovascular collapse, in the operating theatre after receiving routine IV cefazolin prior to induction of anesthesia. She failed to improve with two doses of intramuscular epinephrine followed by two boluses of intravenous epinephrine, but responded to an epinephrine infusion. She was assessed by Internal Medicine and discharged home the following day. This event demonstrates the speed, severity, and profound hypotension in an allergic reaction from intravenous medication, challenges in managing anaphylaxis, and importance of prompt administration of epinephrine via IM route, followed by IV if necessary, in the OR. The case highlighted the inability to ascertain the causative agent through typical allergy testing.

Balloon coronary angioplasty and parenteral antiplatelet therapy for intraoperative myocardial infarction during general surgery: An attempt to balance benefits and risks - a case report

Introduction. Cardiovascular complications remain one of the major risk factors for perioperative morbidity and bad outcome in non-cardiac surgery patients. Here we report a case of the patient suffering intraoperative ST-segment elevation acute myocardial infarction (STEMI) promptly treated with percutaneous balloon angioplasty and intravenous antiplatelet agents. Case report. A 62-year-old man, without previous history of cardiovascular morbidity, developed STEMI during abdominal surgery. Due to profound hypotension with mean arterial pressure of less than 40 mmHg, surgery was promptly ended and patient transferred to intensive care unit. Within one hour after the end of the surgery, coronary angiography and successful balloon angioplasty of occluded right coronary artery were performed. Tirofiban infusion was started in recommended dose. Developed hemodynamic instability was related to hypovolemia and excessive drainage, reaching 1,500 mL of blood in the following 15 hours. The following morning, drainage persisted (additional 600 mL of blood) which resulted in profound hypotension (65/40 mmHg). Overall, the patient received 1,970 mL of blood, 6 doses of thrombocytes and 840 mL of fresh frozen plasma. All together, the patient had a favorable outcome, despite the occurrence of bleeding complications and hemodynamic instability. Conclusion. The choice of treatment strategy for patients suffering perioperative STEMI during major non-cardiac surgery is challenging. After major non-cardiac surgery, characterized by both high bleeding risk and high risk of stent thrombosis, balloon angioplasty instead of stenting along with parenteral antiplatelet treatment may be a fair therapeutic choice. Clinical choices have to be made individually, according to the weighted risks and benefits.

STEMI: rare initial presentation of a mediastinal mass supplied by the RCA

In the setting of severe septic shock, a 70-year-old woman had an ST segment myocardial infarction with ST elevations in the inferolateral leads. On cardiac catheterisation, no obstructive pathology was noted. Chest imaging revealed a large mediastinal mass measuring 8.5×6.5×7.5 cm in the visceral compartment of the mediastinum, with contrast enhancement from the right coronary artery (RCA). A biopsy was preformed and cytology was consistent with a well-differentiated neuroendocrine neoplasm. On review of the cardiac catherisation, it was noted that the mass was deriving blood supply from the RCA. Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a rare but well-documented phenomenon. In this case, MINOCA was caused by coronary steal syndrome in the setting of profound hypotension. Immediate management is with haemodynamic support; there is no role for coronary intervention.

Norepinephrine pressor infusion withdrawal in a National Health Service hospice

Norepinephrine (NE) is a peripheral vasoconstrictor used as an emergency measure to restore blood pressure secondary to acute hypotension. NE must be administered centrally as a continuous infusion and requires intensive monitoring. Consequently, its use is restricted to critical care environments. We discuss the withdrawal of NE in a hospice for a patient with advanced malignancy and profound hypotension from sepsis. The patient was admitted to intensive care but chose to stop active treatment and insisted on being discharged. Due to concerns about withdrawing NE in the community, he was transferred to a local hospice. We describe various challenges, including the administration and monitoring of NE outside of intensive care, the withdrawal process and concerns that profound hypotension might compromise subcutaneous medications absorption.