major limb fracture

[sandiphari]

we have one case of # femure age:45, non DM / obese. we planned ST pin+Debridement. I give  SA with  Lign. Surgery  lasted for 45 min. After shifting pt. to ward ,He developed  Hypotension, Vomiting. we give  fast  iv fluids+hemmaccele. Pt. not improved, so we started meph. He developed Ronchi+ Crepitaion . we started  Dopa+o2 +fluids+hemmaccele .+Deriphylline. no response. Sao2 falling< we intubated pt .Started IPPV .But pt. detoriated . Ultimately Died. What can be the cause?

[yogenbhatt1]

Hi,
That was bad to lose a patient, a young and a fit man.
To me this looks like an embolism, may be fat, may be a clot, leading to hypotension, and then PH leading to failure and death.
The movements of shifting are also responsible for a clot shifting and giving pulm embolism.
Is there something that you can do to  prevent an embolism?????
We have a habit fo taking the blame on our head by feeling that this was a spinal hypotension.
Let us come out of it.

[yogenbhatt1]

Hi again,
Another comment, to make on use of Lignocain in spinal anaesthesia.
Quite a few ppl have stopped using this drug in spinal, specially when a much longer acting drug is available. We put some additives to make it work still longer( alangesia), like Buprigesic - 24 hrs, Clonidine - 8 / 10 hrs, Many even put Butorphenol, Tramadol, Fentanyl and so on.
If we can make the patient painless for a longer time , why use a short acting drug for surgery. Specially ortho cases, where time fundas are ????? Enough time is taken for cleaning and then plastering etc.
This was just a comment and not a suggestion.

[jafo1964]

I agree with Dr. Bhatt's observations

Current evidence suggests that 5% Lignocaine hyperbaric should not be used for SAB
We have given up the drug totally pending further evaluation into 2% hyperbaric lignocaine

Vomiting in SAB is a hallmark of cerebral hypoperfusion and requires emergent intervention.

PE is a possibility
Also could the patient have had occult CAD not picked up on resting ECG. Younger onset coronary ischemia is quite common these days. The patient has developed crepitations indicating probably pulmonary edema probably due to LVF.

In PE, PVR increases and that produces pressure overload on the RV leading to usually RV failure.
ofcourse this could lead to decreased CO and coronary perfusion and finally LVF too

Prevention
all patients having any risk factor for developing PE ( this patient was obese) must receive LMWH ASAP, probably pre-op itself

Having said it let me record the truth
in my centre LMWH is not a routine.
multiple factors including
non-compliant surgeons, drug non-availability, avoidance to perform CNB

regs

[sandiphari]

THANX Dr.YOGENBHAI FOR YOUR EXPERT  OPINION. WE WILL ALSO FOLLOW YOUR ADVICE AND  WILL START USING OTHER DRUGS THAN LIGN.

[yogenbhatt1]

Hi,
Thanks to the site, giving us a forum for a good and healthy discussion.
Dr. Kalpesh wrote quite a few letters. I am glad that he recd a lot of replies.
I hope that Dr. Jafo, with his to- the -point approach, does not become an examiner. He is a class apart. My complements to you sir.