1Department of Anaesthesiology, Niigata University School of Medicine, 1-757 Asahi-machi, Niigata951-8510, Japan. 2Intensive Care Unit, Niigata University School of Medicine, 1-757 Asahi-machi, Niigata 951-8510, Japan. 3Department of Neurology, Niigata University School of Medicine, 1-757 Asahi-machi, Niigata 951-8510, Japan
Accepted for publication: May 5, 2000
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Abstract |
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Keywords: anaesthetic techniques, thoracic epidural; complications, cardiac arrest; complications, hypothermia
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Introduction |
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Case report |
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The patient was admitted to our intensive care unit (ICU) 30 min following resuscitation and his lungs were mechanically ventilated with PEEP (5 cm H2O). Blood gas analysis showed pHa 7.462, PaCO2 33.8 mm Hg, PaO2 128 mm Hg, base excess 1.4 mMol litre1 at FIO2 0.4. An i.v. infusion of thiamylal sodium 24 mg kg1 h1 was started. Muscle rigidity continued to develop despite the barbiturate therapy, and eventually a characteristic decorticate posture developed. The tendon reflexes of all limbs were highly accentuated. The pupillary light reflexes, tested 23 h after transiently stopping the infusion of thiamylal, were absent. The EEG showed no electrical activity, although auditory brainstem responses were present with normal interpeak latencies and delayed peak latencies. Some small respiratory movements were observed and the cerebral circulatory index (CCI, cerebral blood flow divided by cerebral metabolic rate of oxygen which is the inverse of the arterovenous oxygen content difference) was 16 at an oesophageal temperature of 37.2°C.
Computed tomography (CT) on the second day after ICU admission demonstrated an oedematous area in the brain, mainly in the occipital cortex and air in the ventricles which was thought to have been introduced during the epidural injection (Fig. 1). Glycerol (100 mg) and dexamethasone (0.5 mg) were infused i.v. over 2 h, before mild hypothermia (oesophageal temperature 3334°C) was induced by surface cooling. Within 3 days of this treatment, a repeat CT scan showed that the air bubbles in the cerebral ventricles had disappeared and the oedematous shadow was smaller (Fig. 1). On the sixth day after admission to ICU, the decorticate rigidity had decreased but hyperreflexia persisted. The pupils responded to light, and band waves in the EEG were observed at this time. On the 17th day after ICU admission, the infusion of the thiamylal was tapered and rewarming of the body was started. When the oesophageal temperature was 35.5°C, the patient nodded in response to command. Weaning from the ventilator was successful after several trials on the 18th day after ICU admission.
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Discussion |
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There have been previous case reports of the accidental total spinal block and recovery with various neurological disabilities after resuscitation.46 814 However, there have been no reports of adult patients who had decorticate rigidity for several days after cardiac arrest and recovered, except in an elderly patient with accidental hypothermia.15 As our patient had decorticate rigidity and diffuse brain oedema, the clinical outcome seemed desperate at first. However, the CCI was 1618, suggesting a matching of cerebral blood flow and metabolism even though there was EEG silence.16
This case might suggest that intensive treatment with the combined use of mild hypothermia17 and barbiturate therapy should be tried when there is a decorticate rigidity with profound suppression of brainstem reflexes following cardiopulmonary resuscitation. We used thiamylal instead of thiopental in this case, as thiamylal, which has similar pharmacokinetics to thiopental,18 was found to be more effective in attenuating the increase in intracellular calcium concentration produced by NMDA receptor activation than thiopental.19
This case also demonstrates that patients must be continuously monitored by close observation of respiratory, circulatory as well as neurological signs and symptoms for at least 20 min following epidural injection.
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Footnotes |
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References |
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