1Department of Musculoskeletal Science, Royal Liverpool University Hospital, Liverpool L69 3GA, UK. 2Warrington Hospital, Lovely Lane, Warrington WA5 IQG, UK*Corresponding author
Accepted for publication: June 28, 2001
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Abstract |
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Br J Anaesth 2001; 87: 7701
Keywords: antifibrotic agent, ADCON-L anti-adhesion gel; complications, tachycardia; complications, hypotension
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Introduction |
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Methods and results |
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The mean (SEM) systolic pressure before the administration of ADCON-L was 108 (4), and after the application of ADCON-L it decreased to 80 (4). Similarly, the heart rate before ADCON-L was 65 (3) beats min1 and after ADCON-L it increased to 94 (7) beats min1 (Fig. 1). Hypotension was restored to the pre-induction level within an average of 8.7 min (range 315 min) after the administration of i.v. fluids (Hartmans solution, mean volume 1000 ml, and Gelofusine, mean volume 500 ml) and ephedrine 1215 mg given incrementally. None of these hypotensive episodes was associated with hypoxaemia and the ECG showed sinus tachycardia throughout. No patient developed bronchospasm, urticaria or erythema and there was no increase in body temperature. After cardiovascular stability had been restored, a blood sample was obtained and serum tryptase (an indicator of mast cell degranulation and therefore histamine release) was measured.3 Serum tryptase was not identified in any of the patients. All patients remained stable post-operatively and were discharged the next day after an uneventful recovery.
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Discussion |
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Mechanisms that may account for ADCON-L-induced cardiovascular instability include anaphylactic reaction, direct myocardial depression and systemic vasodilatation. Anaphylactic reaction is unlikely because other systemic manifestations of allergy, such as erythema, urticaria, salivation, cyanosis or bronchospasm, were absent. In addition, serum tryptase was not identified in any of the cases.
Myocardial depression and systemic vasodilatation may have occurred secondarily to the systemic absorption of ADCON-L, although, because this substance is used as an implant and not as a drug, it has not been investigated to determine if it has vasoactive properties. However, i.v. fluids and vasopressors were required in moderate doses in order to treat the haemodynamic changes. Intravenous fluids improve myocardial contractility by improving cardiac preload, and they also reverse the haemodynamic effects of a vasodilated circulation. Ephedrine has chronotropic, inotropic and vasoconstrictor properties and therefore directly improves myocardial contractility and reverses systemic vasodilation. Heart rate decreased and blood pressure increased after the administration of i.v. fluid and ephedrine, and we propose that the mechanism of the observed haemodynamic changes is myocardial depression and systemic vasodilatation. The reactions are similar to those described after the use of methylmethacrylate cement, which is used to fix orthopaedic prostheses. In these instances, a transient fall in blood pressure within 1 or 2 min of inserting the methylmethacrylate cement into the medullary canal of the femur is often observed. Usually, arterial pressure returns to normal in 35 min. The adverse effects of methylmethacrylate include systemic vasodilatation and direct myocardial depression secondary to absorption of the methylmethacrylate cement.46 Embolism of fat, air or bone marrow can occur when methylmethacrylate cement is used, but there is no reason to believe that these may have occurred after the administration of ADCON-L.
There are important implications for the anaesthetist whenever ADCON-L is used. We now routinely administer Hartmans solution 1000 ml and Gelofusine 500 ml during surgery and before ADCON-L is administered. In more than 100 consecutive microdiscectomies, no episodes of hypotension have been observed since this practice was introduced.
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References |
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2 de Tribolet N, Porchet F, Lutz TW, et al. Clinical assessment of a novel antiadhesion barrier gel: prospective, randomized, multicenter, clinical trial of ADCON-L to inhibit postoperative peridural fibrosis and related symptoms after lumbar discectomy. Am J Orthop 1998; 27: 11120
3 Fisher M, Baldo B. Mast cell tryptase in anaesthetic anaphylactoid reactions. Br J Anaesth 1998; 80: 269[ISI][Medline]
4 Karisson J, Wendling W, Chen D, et al. Methylmethacrylate monomer produces direct relaxation of vascular smooth muscle in vitro. Acta Anaesthesiol Scand 1995; 39: 6859[ISI][Medline]
5 Pinto PW Cardiovascular collapse associated with the use of methylmethacrylate. AANA J 1993; 61: 6136[Medline]
6 Spiess BD, Sloan MS, McCaffity RJ, et al. The incidence of venous air embolism during total hip arthroplasty. J Clin Anesth 1988; 1: 2530[Medline]