BACKGROUND: Tranexamic acid is a well-known antifibrinolytic medication frequently prescribed to individuals with bleeding disorders. Following accidental intrathecal injection of tranexamic acid, major morbidities and fatalities have been documented. The aim of this case report is to present a novel method for management of intrathecal injection of tranexamic acid.
METHODS: In this case report, a 400 mg intrathecal injection of tranexamic acid resulted in significant back and gluteal pain, myoclonus of the lower limbs, agitation, and widespread convulsions in a 31-year-old Egyptian male with history of left arm and right leg fracture. Immediate intravenous sedation with midazolam (5 mg) and fentanyl (50 μg) was delivered with no response in seizure termination. A 1000 mg phenytoin intravenous infusion and subsequently, induction of general anesthesia was performed by thiopental sodium (250 mg) and atracurium (50 mg) infusion, and the trachea of the patient was intubated. Maintenance of anesthesia was achieved by isoflurane 1.2 minimum alveolar concentration and atracurium 10 mg every 20 minutes, and subsequent doses of thiopental sodium (100 mg) to control seizures. The patient developed focal seizures in the hand and leg, so cerebrospinal fluid lavage was done by inserting two spinal 22-gauge Quincke tip needles, one on level L2-L3 (drainage) and the other on L4-L5. Intrathecal normal saline infusion (150 ml) was done over an hour by passive flow. After cerebrospinal fluid lavage and the patient\'s stabilization was obtained, he was transferred to the intensive care unit.
CONCLUSIONS: Early and continuous intrathecal lavage with normal saline, with the airway, breathing, and circulation protocol is highly recommended to decrease morbidity and mortality. The selection of the inhalational drug as a sedative and for brain protection in the intensive care unit provided possible benefits in management of this event with medication errors.

暂无摘要。

Status epilepticus, when continued despite the administration of two antiepileptic drugs, is called refractory status epilepticus (RSE). The seizure-like phenomenon due to propofol is widely reported in the literature. However, RSE caused by propofol is rare and is a diagnostic dilemma.
A 44-year-old male patient presented with RSE during the intraoperative period and was under general anesthesia on propofol infusion. The seizure was resistant to benzodiazepines and phenytoin. Thereafter, the seizure subsided after the discontinuation of propofol infusion, and the patient was shifted to fentanyl and dexmedetomidine infusion for the maintenance of anesthesia. The postoperative follow-up was uneventful.
This article focuses on the management of intractable intraoperative seizure and highlights the need for the exploration of seizure characteristics caused by propofol.

BACKGROUND: Seizures are rare during the perioperative period; in most cases, there is a previous history of epilepsy or surgery-associated seizures. Febrile convulsions may occur when the body temperature rises above 38°C; this is the most common cause of seizures in children. Febrile convulsions after general anesthesia in the postanesthetic care unit (PACU) without a past or family history are rare. Some reviews suggest that since anesthesia changes immunity, elective surgery should be postponed three weeks after live vaccination.
METHODS: A 12-month-old female with bilateral hearing loss underwent cochlear implantation under general anesthesia. She did not have any history of convulsions or developmental disorders. However, 1 week before surgery, measles-mumps-rubella (MMR) vaccination was given as a regular immunization.
UNASSIGNED: Forty minutes after arrival at the PACU, sudden generalized tonic-clonic movement occurred during recovery and the patient\'s measured body temperature exceeded 38.0°C.
METHODS: Thiopental sodium was administered intravenously as an anticonvulsant, and the tonic-clonic movement stopped immediately. Endotracheal intubation was performed to secure the airway, and tepid massage and diclofenac β-dimethylaminoethanol administration were performed to lower the patient\'s body temperature.
RESULTS: There was no further fever and no seizures, and no other neurological deficits were observed until discharge.
CONCLUSIONS: The anesthesiologist should check the recent vaccination history even if the patient has not developed particular symptoms after vaccination. It is important to know that febrile convulsions may occur in patients who have recently received MMR vaccination.

The victim was a morbidly obese and bull-necked woman in her twenties. She had the disorders, due to Down\'s syndrome, including severe mental retardation, advanced hearing loss, congenital cataract surgery, and amblyopia at postoperative glaucoma. She was deeply sedated for rest with an intravenous drip infusion of 350 mg of thiopental (TP) for 5 minutes during an intraocular pressure examination with secondary glaucoma at a hospital. The examination was finished within 10 minutes after the TP injection, but her respiratory condition deteriorated rapidly when the doctor left the patient. Although immediate artificial respiration was carried out, she was declared dead about 20 hours after the examination. Medical malpractice was suspected for her death. At autopsy, no fatal disease or injury was observed in the victim. The serum TP level was 0.80 µg /ml. TP is an ultra-short-acting intravenous anesthetic, and usually only the smallest amount should be administered by frequent additions after pre-anesthesia administration while maintaining contact with patients. Although contact with patients with a disability can be difficult, it was diagnosed that the death was caused by both respiratory arrest due to a single dose of TP and delay in resuscitation due to the absence of a doctor.

BACKGROUND: Alpha lipoic acid is a powerful antioxidant widely used for the supplementary treatment of diabetic neuropathy. Intoxication with alpha lipoic acid is very rare. There is no reported dose of safety in children.
METHODS: A 14-month-old previously healthy girl was referred to our hospital with the diagnosis of drug intoxication. She was admitted to the emergency department with lethargy and continuing involuntary movements for several hours after she had ingested an unknown amount of alpha lipoic acid. On admission she was lethargic and had myoclonic seizures involving all extremities. She had no fever and laboratory examinations were normal except for mild metabolic acidosis. The seizures were unresponsive to bolus midazolam, phenytoin infusion and levetiracetam infusion. She was taken to the pediatric intensive care unit with the diagnosis of status epilepticus. After failure of the treatment with midazolam infusion she was intubated and thiopental sodium infusion was started. Her myoclonic seizures were controlled with thiopental sodium infusion. After 48 h intubation and mechanical ventilation thiopental sodium was gradually reduced and then stopped. Following the withdraw of thiopental sodium, she was seizure free on her discharge on the 8th day.
CONCLUSIONS: Alpha lipoic acid and derivatives cause side effects in children like refractory convulsions. They are frequently rendered as vitamins by diabetic patients and are left at places where children can easily access them. Therefore, when faced with refractory convulsions in children who have had no disease before, intoxication by medicaments with alpha lipoic acid should be taken into consideration.

暂无摘要。

Thiopental is an ultra-short-acting barbiturate, used as an induction agent during general anesthesia and to manage intra cranial pressure in traumatic brain injuries. Because of its rapid onset of action, the potential for accidental or intentional abuse of thiopental is high. In this paper, a case is presented in which a 25-year-old female deliberately injected a fatal dose of thiopental. A method is developed for the evaluation of thiopental levels in the post-mortem blood (PMB) by simple and rapid HPTLC. Three different extraction procedures were compared for optimum recovery of thiopental from spiked blood samples. The effect of pH on the extraction yield of thiopental over a pH range of 5-6.5 was examined. An average analytical recovery of 90.5% was achieved from an ethyl acetate extract at pH 5.5. Chromatographic separation was achieved on silica gel 60F254 plates with an optimized mobile phase consisted of hexane-dichloromethane-ethyl acetate in the ratio 7.5:2:0.5 (v/v). Densitometric detection was carried out at 290nm in absorbance mode. No significant chromatographic interference was observed from other drugs used to diagnose the brain death. Calibration curve for thiopental in blood were linear from 1 to 100μgml(-1) with r(2)=0.994. The detection limit was 0.5μgml(-1) and its lower limit of quantification was 1.5μgml(-1). The method showed excellent intra-assay precision (R.S.D. 1.07-6.28%) and inter-assay precision (R.S.D. 0.39-1.43%) for spiked blood samples at concentration of 1, 10, and 50μgml(-1). The toxicological analysis revealed high concentrations of thiopental in PMB (204.75μgml(-1) ±0.34), which is of immense help to conclude that the death occurred due to fatal doses of thiopental.

The authors report an unusual case of suicide of an anesthesiologist, in which the suicide manner and means depend upon the victim\'s occupation. This is the first case report published in Italy of a death involving propofol and other drugs. The anesthesiologist was found dead with an empty drip still inserted in the hand and another one near his body. Forensic and toxicological findings suggested that the cause of death was a respiratory depression due to a self-administration of a rapidly infused lethal drug mixture. Analytical drug quantification was performed by gas chromatography-mass spectrometry. Blood analysis revealed: zolpidem (0.86 μg/mL), propofol (0.30 μg/mL), midazolam (0.08 μg/mL), thiopental (0.03 μg/mL), and amitriptyline (0.07 μg/mL). Adipose tissue and hair analysis suggested a previous and repeated use of these drugs verifying the fact that in Italy recreational abuse of anesthetic and sedative agents in health care practitioners is becoming an increasing problem.

Postictal agitation (PIA) with possible severe implications occurs in approximately 10% of electroconvulsive therapy (ECT) sessions. The pathomechanism is not well understood, and suggested treatments are empirical based. We report a case of repetitive (47/57 sessions [83%]) severe PIA after ECT in a case with severe depression. If the minimal bispectrum EEG index (BIS) value, meaning the deepest level of sedation of the thiopental narcosis dropped below 50, PIA occurred in only 9.1%. Bispectral index (BIS) monitoring made prediction and prevention of PIA possible to some degree. Postictal agitation might occur in vulnerable patients when initial depth of anesthesia is too light.