BMJ case reports
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We present the case of a 56-year-old man who developed chronic pain following the excision of a facial cancer that was poorly controlled despite multiple analgesic medications. Following the starting of nabilone (a synthetic cannabinoid) his pain control was greatly improved and this had a huge impact on his quality of life. We also managed to significantly reduce his doses of opioid analgesia and ketamine. We review the current literature regarding the medicinal use of cannabinoids, with an emphasis on chronic pain, in an attempt to clarify their role and how to select patients who may benefit from this treatment.
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We describe our experience of a 71-year-old patient with severe renal failure, who exhibited an unusually prolonged rocuronium-induced neuromuscular blockade (>4 h) and apparent recurarisation, following emergency rapid sequence induction (RSI). At the end of operation, 45 min post induction, train-of-four (TOF) testing had been 4/4 prior to wake up. No respiratory effort was seen 150 min postinduction, despite further neostigmine/glycopyrrolate and repeat TOF 4/4. ⋯ At 180 min postinduction, fade was evident on TOF, suggestive of rocuronium reblockade. At 285 min, the patient was extubated safely following sugammadex administration and discharged uneventfully from the ICU. An important lesson to recognise is the potential for extremely prolonged neuromuscular blockade following rocuronium in patients with severe renal failure, particularly when using the higher doses (1.2 mg/kg) required for RSI, and that TOF in such cases may not be reliable in detecting residual blockade.
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A 28-year-old woman presented to accident and emergency department with a 1-day history of right-sided abdominal pain. She was afebrile, and haemodynamically stable, and the initial diagnosis was acute appendicitis. A transvaginal ultrasound scan was performed and was suggestive of appendicitis. ⋯ Postoperatively the patient complained of persisting pain, which settled over 2 days with analgesia and antibiotics. This case is an extremely unusual case of epiploic appendagitis and acute appendicitis. It demonstrates the importance of pelvic laparoscopy in all females with presumed appendicitis, even in the presence of an initial pathology.
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Case Reports
Atypical intraoperative anaphylactic shock with ECG changes secondary to non-ruptured hepatic hydatid cyst.
A 62-year-old woman was admitted to the hospital for removal of hydatid cyst from the liver. Intraoperatively, the patient suddenly became hypotensive with tachycardia and ST segment elevation. There was no erythema, bronchospasm or desaturation. ⋯ Histopathology confirmed hydatid disease of the liver. The patient was discharged from the ICU and then from the hospital in 6 days. Anaphylaxis secondary to hydatid disease is uncommon; however, the possibility of such a diagnosis in all patients with non-ruptured hydatid disease in the endemic areas that develop intraoperative shock should be considered.
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A 72-year-old man was admitted to our clinic because of pain in the right eye. Corneal oedema, peripheral anterior synechiae formation and intraocular lens were determined in the right eye. The left eye was normal except for nuclear sclerosis. ⋯ In the detailed anamnesis of the patient, we discovered that he had used a topical anaesthetic instead of the prescribed medicine owing to ocular pain. The patient was still using topical anaesthetic eye drops, despite warnings. Finally, evisceration was performed on his right eye because of corneal melting and perforation.