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underwent cervical esophagostomy and gastrostomy. We
started diltiazem tablets through gastrostomy. Post‑operative
period was uneventful. He could be discharged from
hospital after definitive surgery. He is now under cardiology
follow‑up.
In view of non‑specific presentation of Boerhaave’s
syndrome; CECT scan is essential to “detect the presence,
site and size of esophageal perforation” and to guide proper
treatment.[2,3] For CECT scan of thorax and abdomen,
iohexol dye is preferred as oral contrast as it has low
osmolarity and less adverse effects.[4] Osmotically related
nephrotoxicity and anaphylactic‑type reactions are the main
adverse effects reported after intravenous iodinated dye
exposure.[1,4] To our knowledge, this is the first reported
case of adverse reaction like AF following oral contrast
dye instillation. We strongly believe that hemodynamically
unstable AF, in our case, is due to direct contact of oral
contrast dye around aorta and pericardium.[5] Injection
of dye over the pericardium might initiated a pericardial
inflammatory reaction, which precipitated AF.[6] The
physical process of instillation of a viscous solution
or lower (room temperature 22°C) temperature of the
instillate near the cardiac chambers might triggered AF.
Anaphylactoid reaction after oral dye exposure might be
a cause.[4] Pneumomediastinum is a known cause of AF
and might be a possibility in our patient.[7] Importantly,
his old age and a past history suggestive of lone AF, and
stoppage of beta adrenergic blocker (first for the suspected
esophageal tear and then for septic shock) might make him
susceptible for this life threatening episode.[6,8]
We, in conclusion, want to highlight that oral iodinated
dye instillation can cause hemodynamically unstable
AF in cases of suspected esophageal perforation may
be due to direct mediastinal instillation and stimulation
of cardiac structures. Oral dye in those cases should be
instilled in presence of hemodynamic monitoring and
defibrillator (preferably in ICU setting).
Anesthesia for a patient with thrombocytosis
Sir,
A 70‑year patient, a known case of hypertension, presented
with history of bilateral knee pain from the last 3 years.
A detailed history, examination and workup diagnosed
bilateral osteoarthritis.
Vol. 7, Issue 4, October-December 2013 Saudi Journal of Anaesthesia
Tanmoy Ghatak, Ratender K. Singh, Sukhen Samanta
Department of Critical Care Medicine, SGPGIMS,
Lucknow, Uttar Pradesh, India
Address for correspondence:
Dr. Tanmoy Ghatak,
Rammohan Pally, Arambagh,
Hooghly - 712 601, West Bengal, India.
E‑mail: tanmoyghatak@gmail.com
REFERENCES
1. Singh J, Daftary A. Iodinated contrast media and their
adverse reactions. J Nucl Med Technol 2008;36:69‑74.
2. Huber‑Lang M, Henne‑Bruns D, Schmitz B, Wuerl P.
Esophageal perforation: Principles of diagnosis and surgical
management. Surg Today 2006;36:332‑40.
3. Fadoo F, Ruiz DE, Dawn SK, Webb WR, Gotway MB.
Helical CT esophagography for the evaluation of suspected
esophageal perforation or rupture. AJR Am J Roentgenol
2004;182:1177‑9.
4. Seymour CW, Pryor JP, Gupta R, Schwab CW. Anaphylactoid
reaction to oral contrast for computed tomography. J Trauma
2004;57:1105‑7.
5. Slinger PD, Campos JH. Anesthesia for thoracic surgery. In:
Miller RD, editor. Miller’s Anesthesia. 7th ed. Philadelphia:
Elsevier, Churchill Livingstone; 2010. p. 1823, 1831.
6. Tapio H, Jari H, Kimmo M, Juha H. Prevention of atrial fibrillation
after cardiac surgery. Scand Cardiovasc J 2007;41:72‑8.
7. Paluszkiewicz P, Bartosinski J, Rajewska‑Durda K,
Krupinska‑Paluszkiewicz K. Cardiac arrest caused by tension
pneumomediastinum in a Boerhaave syndrome patient. Ann
Thorac Surg 2009;87:1257‑8.
8. Schoonderwoerd BA, Smit MD, Pen L, Van Gelder IC. New
risk factors for atrial fibrillation: Causes of ‹not‑so‑lone atrial
fibrillation›. Europace 2008;10:668‑73.
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The patient was electively scheduled for a staged bilateral
knee arthroplasty. Pre‑op investigations incidentally
detected an abnor mally elevated platelet count 
(11.4 lakhs) and anemia (Hb: 9.8). A repeat platelet count
was sought. The platelet count was found to be again
high (10.15 lakhs). The patient was asymptomatic and had
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Letters to Editor
not suffered from any thrombotic/bleeding episodes. All
other parameters were within normal limits. A peripheral
smear was obtained on the advice of the physician and the
smear revealed moderate–severe anisopoikilocytosis and a
microcytic hypochromic anemia with many ovalocytes/pencil
cells and severe thrombocytosis. An ultrasonography of the
abdomen was performed and it revealed mild splenomegaly
with normal echogenicity. The physician recommended a
bone marrow study and the marrow study was planned in
the intra‑op period during the Total Knee Arthroplasty.
The patient and attendants were explained the risk and
also the fact that a bone marrow sample would be taken
in the intra‑op period. In view of the thrombocytosis
and the possibility of bleeding, spinal/epidural anesthesia
was avoided. The surgery was performed under GA with
femoral‑sciatic nerve block. The femoral‑sciatic nerve
block was given prior to induction using ultrasound and
peripheral nerve stimulator guidance. After induction
with propofol, fentanyl and atracurium, the anesthesia
was maintained with oxygen/Nitrous oxide/sevoflurane/
atracurium combination. The bone marrow sample was
taken by the surgeon before proceeding for implantation
and despatched to the laboratory. The intra‑op period was
uneventful. Post‑operatively the patient was transferred
to the Intensive Care Unit as per institutional protocol
and monitored for 24 h and then shifted to the ward. The
post‑op course was stable.
On follow‑up, the bone marrow biopsy revealed a
hypercellular marrow with megakaryocytic hyperplasia.
Megakaryocytes were increased in number (4-5/hpf) with
clustering. A possibility of essential thrombocythemia was
suggested based on the bone marrow findings.
Very few cases of patients with thrombocytosis presenting
for surgery have been reported. The main concerns for us
as anesthesiologists is the risk of thrombotic episodes (MI/
pulmonary infarcts) and the risk of excess bleeding during
the peri‑op period. Choice of anesthesia depends on the
pre‑op platelet count and aggregation studies. Spinal/
epidural is not contraindicated if these investigations are
within normal limits. A detailed history of such episodes
in the past must be sought and the risks involved must be
clearly explained to the patient.
In our case, we were fortunate to not encounter any
problems. Okada and colleagues have reported two cases
of patients presenting with the same problem.[1] They used
an antiplatelet agent gabexate mesilate in the peri‑op period
in these patients.
Kimura and colleagues have also reported anesthesia for
two patients with essential thrombocythemia, which is
myeloproliferative disorder.[2] In one case, the pre‑op platelet
Saudi Journal of Anaesthesia Vol. 7, Issue 4, October-December 2013
Page | 481
count was normal after myelosuppression therapy and they
used a combination of GA with epidural. In the second case,
as the platelet count was deranged, they chose only GA.
Garcia and colleagues have reported the use of spinal
anesthesia in a patient with essential thrombocythemia.[3] In
their case, the patient’s pre‑op platelet counts and aggregation
studies were normal and they proceeded with spinal
anesthesia without any untoward events. Contrary to
this, Meyer and colleagues reported a case of massive
hemorrhage following multiple epidural punctures in a
patient with thrombocythemia.[4] In their case, the patient
suffered from chronic myeloid leukemia and had an
abnormally elevated platelet count.
Thrombocytosis is not always essential thrombocythemia
and this can only be diagnosed with a bone marrow study.
In conclusion, the major concerns in the peri‑op period in
these patients remain the risk of thrombotic and bleeding
episodes. Spinal/epidural anesthesia is not absolutely
contraindicated if the pre‑op tests are within normal limits.
However caution is warranted.
Bharath Kumar TV, Poorna Madhusudan1
Departments of Critical Care, Fortis Hospitals,
1
Anesthesia, Apollo Hospitals, Bangalore, Karanataka, India
Address for correspondence:
Dr. Bharath Kumar TV,
Number 1554, 16th Main, JP Nagar, 2nd Phase,
Bangalore - 560 078, Karnataka, India.
E‑mail: bharathkumartv@gmail.com
REFERENCES
1. Okada Y, Hino H, Nagahama H, Kinouchi H, Sakomoto M,
Aoki T. Anesthesia in two patients with thrombocythemia.
Masui. Japanese J Anaesthesiol 1997;46:1470‑3.
2. Kimura Y, Yamaguchi S, Nagao M, Mishio M, Okuda Y,
Kitajima T. Anesthetic management of two patients with
essential thrombocythemia. Masui, Japanese J Anaesthesiol
2001;50:545‑7.
3. Garcia FJ, Hernandez PJ, Garcia AC, Verdu TM. Subarachnoid
block in a patient with essential thrombocythemia. Anesth
Analg 2005;101:300.
4. Meyer  HH, Mlasowsky  B, Ziemer  G, Tryba  M. Massive
haemorrhage following multiple epidural punctures as a
late complication in thrombocythemia. Anasth Intensivther
Notfallmed 1985;20:287‑8.
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DOI:
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