Tuberculous meningoencephalitis associated with brain tuberculomas during pregnancy: a case report

Tuberculous meningitis is globally highly prevalent and is commoner in resource-limited countries and in patients with immunosuppression. Central nervous system tuberculosis is one of the severest forms of ext...

http://ift.tt/2t3gZW8

Febrile headache and leg weakness as the initial symptoms of tickborne encephalitis

Description

A 61-year-old woman presented to the emergency department (ED) with a 1-week fever associated with progressive headache. She also reported weakness and paraesthesias in both legs. In the ED, the patient had normal vital parameters and reported no other medical history. Clinical examination showed a slight neck stiffness; the rest of the examination was normal. Laboratory findings showed a mild inflammatory syndrome. The patient had a lumbar punction; the cerebrospinal fluid (CSF) showed moderate pleocytosis (140 leucocytes/μL with a mononuclear cell dominance). After a normal CT scan, an MRI examination was performed (figures 1and 2). Several days later, intrathecal IgM and IgG antibodies came back positive.

Figure 1

T2-weighted transverse MRI. Localised hyperintense band involving the tegmentum pontis (arrow heads) and the cerebellar vermis (arrow).

Figure 2

Coronal MRI, fluid attenuation inversion recovery...

http://ift.tt/2t3mZhW

Necrotising coronaritis with fatal outcome

A 56-year-old woman presented with acute onset of typical chest pain. She was diagnosed with acute coronary syndrome with ST-segment elevation myocardial infarction. Although significant obstructive coronary artery disease was ruled out by coronary angiography, cardiac MRI showed transmural necrosis of the lateral free wall with extensive microvascular obstruction consistent with ischaemic heart disease. Within 48 hours after initial presentation, the patient suddenly arrested due to pulseless electrical activity with futile resuscitation efforts. Autopsy revealed myocardial perforation with extensive haematothorax due to pericardial laceration, caused by the mechanical chest compressions. Eventually, histology identified diffuse necrotising coronary vasculitis as a rare cause of ischaemic heart disease.

http://ift.tt/2ukuFeQ

Cohort study of preoperative blood pressure and risk of 30-day mortality after elective non-cardiac surgery

British Journal of Anaesthesia, 119(1): 65–77 (2017), DOI 10.1093/bja/aex056

http://ift.tt/2s2t78K

Quality metrics: hard to develop, hard to validate

In this issue of the British Journal of Anaesthesia, Epstein and colleagues¹ report their findings surrounding the proposed use of intraoperative hypotension as a quality metric for comparison of anaesthetists. The authors analysed a retrospective data set derived from 10 yr of data from their anaesthesia information management system, focusing specifically on a cohort of patients undergoing surgery at an increased risk of postoperative myocardial injury. The availability of electronic health records has enabled big data approaches for quality improvement and outcomes research in anaesthesia.²³ Anaesthetists performing these procedures were compared based on the time-weighted area under the curve for postinduction hypotension (defined as a mean arterial pressure of <65 mm Hg) over 2 month intervals. Recent evidence reviewed by Epstein and colleagues¹ has implicated intraoperative hypotension in adverse outcomes after cardiac and non-cardiac surgery, and additional relevant studies will appear in the British Journal of Anaesthesia.⁴⁵ The authors showed, convincingly, that because of the wide distribution of hypotension across providers and time epochs, intraoperative hypotension cannot be used alone as a quality metric to compare anaesthetists.

http://ift.tt/2s2r8kM

Predicting postoperative morbidity in adult elective surgical patients using the Surgical Outcome Risk Tool (SORT)

Abstract

Background. The Surgical Outcome Risk Tool (SORT) is a risk stratification instrument used to predict perioperative mortality. We wanted to evaluate and refine SORT for better prediction of the risk of postoperative morbidity.Methods. We analysed prospectively collected data from a single-centre cohort of adult patients undergoing major elective surgery. The data set was split randomly into derivation and validation samples. We used logistic regression to construct a model in the derivation sample to predict postoperative morbidity as defined using the validated Postoperative Morbidity Survey (POMS) assessed at 1 week after surgery. Performance of this 'SORT-morbidity' model was then tested in the validation sample and compared against the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM).Results. The SORT-morbidity model was constructed using a derivation sample of 1056 patients and validated in a further 527 patients. SORT-morbidity was well calibrated in the validation sample, as assessed using calibration plots and the Hosmer–Lemeshow test (χ²=4.87, P=0.77). It showed acceptable discrimination by receiver operating characteristic curve analysis [area under the receiver operating characteristic curve (AUROC)=0.72, 95% confidence interval: 0.67–0.77]. This compared favourably with POSSUM (AUROC=0.66, 95% confidence interval: 0.60–0.71), whilst being simpler to use. Linear shrinkage factors were estimated, which allow the SORT-morbidity model to predict a range of alternative morbidity outcomes with greater accuracy, including low- and high-grade morbidity, and POMS at later time points.Conclusions. SORT-morbidity can be used before surgery, with clinical judgement, to predict postoperative morbidity risk in major elective surgery.

http://ift.tt/2s27yF9

Sleep deprived and unprepared

Recent UK government policy initiatives concerning 24/7 care have once again put the spotlight on work after hours. The unavoidable night shift confronts us on a regular basis with the physical, psychological, social, and emotional impacts of acute sleep deprivation and fatigue. Although the function of sleep is still not fully understood, it is undoubtedly vital for our good health and well-being. Regardless, on average we are sleeping less now than we ever did before. As a result, there is endless debate about the dangers of long working hours vs the benefits of continuity of care. Intriguingly, very little is actually known about the impact of delaying sleep on our behaviour as a team member in an unpredictable environment such as the emergency room, operating room, or intensive care unit.

http://ift.tt/2tlbULq

Predictor of fluid responsiveness in the ‘grey zone’: augmented pulse pressure variation through a temporary increase in tidal volume

Abstract

Background: Pulse pressure variation (PPV) is widely used as a predictor of fluid responsiveness. However, a previous study has suggested a 'grey zone' between 9 and 13% in which PPV would be inconclusive to predict fluid responsiveness. Considering PPV is based on cardiopulmonary interactions, we evaluated whether an augmented PPV using a temporary increase in tidal volume (V_T) from 8 to 12 ml kg⁻¹ has the predictability for fluid responsiveness in patients within the grey zone.Methods: Adult patients requiring general anaesthesia were enrolled. During the period when PPV was within the range of 9–13%, haemodynamic variables such as stroke volume index (SVI) and PPV with an 8 ml kg⁻¹ tidal volume ventilation (PPV8) were obtained before and after volume expansion (6 ml kg⁻¹) under mechanical ventilation. Augmented PPV induced by 2-min ventilation with a V_T of 12 ml kg⁻¹ (PPV12) was also recorded immediately before volume loading. The patients whose SVI increased ≥10% after volume expansion were considered responders.Results: In 38 enrolled patients, 20 were responders. Receiver operating characteristic curve analysis showed PPV12 had an excellent predictability for fluid responsiveness {area under the curve [AUC]=0.935 [95% confidence interval (CI) 0.805–0.989]; sensitivity 95%; specificity 72%; P<0.0001}. The optimal threshold for PPV12 was >17%. However, PPV8 failed to show significant predictability [AUC=0.668 (95% CI 0.497–0.812); sensitivity 65%; specificity 61%; P=0.06].Conclusion: In mechanically ventilated patients, our augmented PPV successfully predicted fluid responsiveness in the previously suggested grey zone.Clinical trial registration: ClinicalTrials.gov, NCT02653469.

http://ift.tt/2s2pxLR

Supplemental oxygen and surgical site infection: getting to the truth

Surgical site infection (SSI) remains one of the most serious and expensive postoperative complications.¹ Infected patients are twice as likely to need admission to critical care and twice as likely to die.² The primary defence against SSI is oxidative killing by neutrophils, and molecular oxygen is the substrate.³ Resistance to infection is thus a strong function of tissue oxygen partial pressure over the clinical range. One might thus expect that supplemental perioperative oxygen (∼80%) would reduce infection risk when compared with more traditional inspired oxygen concentrations (∼30%) during anaesthesia and surgery. Despite some early evidence supporting the role of supplemental oxygen in reducing the risk of SSI,⁴ there have since been conflicting results from numerous randomized clinical trials. The most compelling data come from the PROXI trial,⁵ a large, multicentre, randomized trial enrolling 1400 patients undergoing abdominal surgery. This trial found no evidence of any beneficial effect of supplemental oxygen; SSI occurred in 131 of 685 patients (19%) receiving 80% oxygen and in 141 of 701 (20%) receiving 30% oxygen [odds ratio 0.94 (95% confidence interval 0.72–1.22), P=0.64]. Indeed, a long-term follow-up study (median 2.3 years after surgery) found poorer survival in the supplemental oxygen group.⁶

http://ift.tt/2tl2G1M

Continuous monitoring and feedback of quality of recovery indicators for anaesthetists: a qualitative investigation of reported effects on professional behaviour

Abstract

Background: Research suggests that providing clinicians with feedback on their performance can result in professional behaviour change and improved clinical outcomes. Departments would benefit from understanding which characteristics of feedback support effective quality monitoring, professional behaviour change and service improvement. This study aimed to report the experience of anaesthetists participating in a long-term initiative to provide comprehensive personalized feedback to consultants on patient-reported quality of recovery indicators in a large London teaching hospital.Methods: Semi-structured interviews were conducted with 13 consultant anaesthetists, six surgical nursing leads, the theatre manager and the clinical coordinator for recovery. Transcripts were qualitatively analysed for themes linked to the perceived value of the initiative, its acceptability and its effects upon professional practice.Results: Analysis of qualitative data from participant interviews suggested that effective quality indicators must address areas that are within the control of the anaesthetist. Graphical data presentation, both longitudinal (personal variation over time) and comparative (peer-group distributions), was found to be preferable to summary statistics and provided useful and complementary perspectives for improvement. Developing trust in the reliability and credibility of the data through co-development of data reports with clinical input into areas such as case-mix adjustment was important for engagement. Making feedback specifically relevant to the recipient supported professional learning within a supportive and open collaborative environment.Conclusions: This study investigated the requirements for effective feedback on quality of anaesthetic care for anaesthetists, highlighting the mechanisms by which feedback may translate into improvements in practice at the individual and peer-group level.

http://ift.tt/2s2msex

Intraoperative fraction of inspired oxygen: bringing back the focus on patient outcome

Over the last two decades, several randomized controlled trials (RCTs) have investigated the clinical impact of a higher fraction of inspired oxygen (Fi_O2) administered in the perioperative period. Setting Fi_O2 in the operating theatre and after surgery is one of the daily tasks of every anaesthetist, and in elective surgery in uncomplicated patients is often based on the clinician's habits, training, and local clinical practice, rather than on evidence-based guidelines.

http://ift.tt/2tl8TLj

Supraglottic jet oxygenation and ventilation enhances oxygenation during upper gastrointestinal endoscopy in patients sedated with propofol: a randomized multicentre clinical trial

Abstract

Background. Hypoventilation is the main reason for hypoxia during upper gastrointestinal endoscopy procedures with sedation. The key to preventing hypoxia is to maintain normal ventilation during the procedure. We introduced supraglottic jet oxygenation and ventilation (SJOV) through a new Wei nasal jet tube (WNJ) to reduce the incidence of hypoxia in patients sedated with propofol during upper gastrointestinal endoscopy procedures.Methods. In a multicentre, prospective randomized single-blinded study, 1781 outpatients undergoing routine upper gastrointestinal endoscopy who were sedated with propofol by an anaesthetist were randomized into the following three groups: the supplementary oxygen via nasal cannula group [nasal cannula oxygen: O₂ (2 litres min⁻¹) was administered via a nasal cannula]; the supplementary oxygen via WNJ group [WNJ oxygen: O₂ (2 litres min⁻¹) was administered through a WNJ]; and the SJOV via WNJ group (WNJ SJOV: SJOV was administered via WNJ) at three centres from March 2015 to July 2016. The primary outcome of interest was the incidence of hypoxia (peripheral oxygen saturation of 75–89%). Other adverse events were also recorded.Results. Supraglottic jet oxygenation and ventilation decreased the incidence of hypoxia from 9 to 3% (P<0.0001). No severe hypoxia occurred in the WNJ SJOV group, one instance occurred in the WNJ oxygen group, and two instances were observed in the nasal cannula oxygen supply control group. Supraglottic jet oxygenation and ventilation-related minor adverse events increased significantly within 1 min after the procedure but decreased 30 min later.Conclusions. The use of SJOV during upper gastrointestinal endoscopy for patients who are sedated with propofol reduces the incidence of hypoxia, with minor and tolerable adverse events. Supraglottic jet oxygenation and ventilation has a favourable risk-to-benefit ratio and may improve patient safety.Clinical trial registration. NCT02436018.

http://ift.tt/2s2BFMK

Methodology in systematic reviews of goal-directed therapy: improving but not perfect

There has been a recent tsunami of articles on goal-directed (fluid) therapy, haemodynamic optimization and validation of cardiovascular monitoring devices. This has been followed by a wave of systematic reviews, in particular over the last five years, trying to summarize and derive conclusions and recommendations from many of these studies.^1–19 Terminology for systematic reviews and meta-analyses is frequently used incorrectly. A systematic review refers to a rigorous scientific process of reviewing relevant literature whereas meta-analysis refers to a statistical method of pooling data from multiple studies to derive a summary effect estimate. Any well-conducted scientific process needs to comply with quality standards. Likewise, systematic reviews need to meet quality criteria before qualifying for the highest level of evidence (http://ift.tt/17HmMli, accessed May 29, 2017), including a sufficiently detailed published protocol, full search strategy in multiple databases, outcome selection following GRADE²⁰ (http://ift.tt/YgVdNI, accessed May 29, 2017), assessment of risks of bias, assessment of risks of random errors, and reporting results following PRISMA²¹ and GRADEpro. Producing pooled estimates is always tempting whereas frequently not pooling data because of large heterogeneity might be much wiser. Eventually, only a few systematic reviews qualify for Level 1A evidence.

http://ift.tt/2tlpvTj

Association between preoperative pulse pressure and perioperative myocardial injury: an international observational cohort study of patients undergoing non-cardiac surgery

Abstract

Background. The management of elevated blood pressure before non-cardiac surgery remains controversial. Pulse pressure is a stronger predictor of cardiovascular morbidity in the general population than systolic blood pressure alone. We hypothesized that preoperative pulse pressure was associated with perioperative myocardial injury.Methods. This is a secondary analysis of the Vascular Events in Non-cardiac Surgery Patients Cohort Evaluation (VISION) international cohort study. Participants were aged ≥45 yr and undergoing non-cardiac surgery at 12 hospitals in eight countries. The primary outcome was myocardial injury, defined using serum troponin concentration, within 30 days after surgery. The sample was stratified into quintiles by preoperative pulse pressure. Multivariable logistic regression analysis explored associations between pulse pressure and myocardial injury. We accounted for potential confounding by systolic blood pressure and other co-morbidities known to be associated with postoperative cardiovascular complications.Results. One thousand one hundred and ninety-one of 15 057 (7.9%) patients sustained myocardial injury, which was more frequent amongst patients in the highest two preoperative pulse pressure quintiles {63–75 mm Hg, risk ratio (RR) 1.14 [95% confidence interval (CI): 1.01–1.28], P=0.03; >75 mm Hg, RR 1.15 [95% CI: 1.03–1.29], P=0.02}. After adjustment for systolic blood pressure, preoperative pulse pressure remained the dominant predictor of myocardial injury (63–75 mm Hg, RR 1.20 [95% CI: 1.05–1.37], P<0.01; >75 mm Hg, RR 1.25 [95% CI: 1.06–1.48], P<0.01). Systolic blood pressure >160 mm Hg was not associated with myocardial injury in the absence of pulse pressure >62 mm Hg (RR 0.67 [95% CI: 0.30–1.44], P=0.31).Conclusions. Preoperative pulse pressure >62 mm Hg was associated with myocardial injury, independent of systolic blood pressure. Elevated pulse pressure may be a useful clinical sign to guide strategies to reduce perioperative myocardial injury.

http://ift.tt/2s27u8n

Some light in the grey zone?

Treatment of shock is not a new concern in intensive care medicine. The highest priority in patients with shock is the restoration of oxygen delivery. Fluid resuscitation is the very first goal of increasing cardiac output and oxygen delivery in patients with acute circulatory insufficiency. First, based on the simple physiology of the Frank–Starling mechanism, fluid loading should increase cardiac output (CO) by increasing preload and subsequently increasing left ventricular (LV) stroke volume.¹ However, fluid overload, especially in patients with pre-existing or developing cardiac failure, can end in only a fractional increase of stroke volume and negative effects like pulmonary venous congestion can predominate. It is therefore a daily task for each intensivist to identify those patients who will respond to and benefit from volume expansion (e.g. acute shock) and to avoid fluid overload in those who are no longer fluid responsive but are at risk for increased mortality by further fluid therapy (e.g. protracted sepsis, acute respiratory distress syndrome, acute kidney injury). Thus the therapeutic conflict between hypovolaemia and hypervolaemia needs to be addressed wisely. Consequently, precise monitoring of preload could be helpful in this clinical scenario (Fig. 1).

http://ift.tt/2tlbzIT

Hypotension during induction of anaesthesia is neither a reliable nor a useful quality measure for comparison of anaesthetists’ performance

Abstract

Background. Identification of statistically reliable outcomes for comparison among anaesthetists is challenging. Time-weighted intraoperative mean arterial pressure <65 mm Hg (AUC₆₅) is associated with increased odds for myocardial damage. We explored retrospectively whether such hypotension before incision was statistically reliable for peer comparison.Methods. We retrieved electronic data between 2006 and 2015 at a tertiary care, academic hospital in the USA for patients at risk for myocardial damage (inpatient after surgery, ASA physical status ≥III, ≥50 yr of age, and case duration ≥60 min). We determined the percentage of anaesthetists comparable based on caseload and case-mix. The AUC₆₅ was compared amongst anaesthetists supervising ≥100 cases involving at-risk patients during the last 12 months.Results. Only 14.1% [95% confidence interval (CI) 13.6–14.5%] of cases involved patients who were 'at risk' during the 10 yr study period. A yearly average of 49 (sd 6) anaesthetists supervised ≥100 cases of any type, of whom only 52% (95% CI 47.1–56.0%) supervised ≥100 cases involving at-risk patients. Thus, nearly half the anaesthetists would have been excluded from peer comparison. During the last 12 months, there were two outliers among 34 evaluable anaesthetists (P<0.05, controlling for false discovery). However, their contribution to total hypotension amongst cases for all patients was small, because hypotension was widely distributed (e.g. 80% of hypotension attributable to 61.8% of anaesthetists, 95% CI 59.8–63.7%). There was no relationship between the AUC₆₅ and propofol induction dose.Conclusions. The AUC₆₅ of time-weighted pre-incision hypotension is not a suitable metric for comparing anaesthetists. There were few at-risk patients, half the anaesthetists were not evaluable because of their case-mix and caseload, and hypotension was widely distributed.

http://ift.tt/2s2gzhB

The Goldilocks principle as it applies to perioperative blood pressure: what is too high, too low, or just right?

In this issue of the British Journal of Anaesthesia, Professor Venkatesan and colleagues,¹ using data from the large UK Clinical Practice Research Datalink (CPRD) database, found a significant association between low preoperative arterial blood pressure (BP) values and increased postoperative mortality, but only in an elderly population of patients. The risk thresholds started at a preoperative systolic BP of 119 mm Hg and diastolic BP of 63 mm Hg compared with a reference BP of 120 mm Hg. Elevated diastolic, but not systolic BP, was also associated with increased mortality in the entire cohort of patients. These BP readings are considered within the normal, in fact optimal, ranges of acceptable BP for long-term control. Readers should not be surprised that elevated BP was associated with adverse outcomes. However, the findings that only elevated diastolic readings, not systolic hypertension, and 'low' (though the adjective 'lower' would likely be more descriptive of the actual findings) BP are associated with mortality are novel findings. The findings regarding low BP add weight to a growing body of observational data suggesting intraoperative hypotension is associated with adverse outcome. This article challenges us to perhaps be as concerned about low BP readings as we are about elevated BP in the preoperative as well as intraoperative periods.

http://ift.tt/2tkTsTb

Impact of sleep deprivation on anaesthesia residents’ non-technical skills: a pilot simulation-based prospective randomized trial

Abstract

Background. Sleep deprivation is common in anaesthesia residents, but its impact on performance remains uncertain. Non-technical skills (team working, situation awareness, decision making, and task management) are key components of quality of care in anaesthesia, particularly in crisis situations occurring in the operating room. The impact of sleep deprivation on non-technical skills is unknown. We tested the hypothesis that in anaesthesia residents sleep deprivation is associated with impaired non-technical skills.Methods. Twenty anaesthesia residents were randomly allocated to undergo a simulation session after a night shift [sleep-deprived (SLD) group, n=10] or after a night of rest [rested (R) group, n=10] from January to March 2015. The simulated scenario was a situation of crisis management in the operating room. The primary end point was a composite score of anaesthetists' non-technical skills (ANTS) assessed by two blinded evaluators.Results. Non-technical skills were significantly impaired in the SLD group [ANTS score 12.2 (interquartile range 10.5–13)] compared with the R group [14.5 (14–15), P<0.02]. This difference was mainly accounted for by a difference in the team working item. On the day of simulation, the SLD group showed increased sleepiness and decreased confidence in anaesthesia skills.Conclusions. In this randomized pilot trial, sleep deprivation was associated with impaired non-technical skills of anaesthesia residents in a simulated anaesthesia intraoperative crisis scenario.Trial registration. NCT02622217.

http://ift.tt/2tliNwC

Rising sudden death among anaesthesiologists in China

Editor—Anaesthesiologists in China are currently suffering from work overload, and sudden death is increasing dramatically. A recent sudden death of a young anaesthesiologist in a local hospital followed an overnight of on-duty work; the second sudden death of a young anaesthesiologist this spring. In 2014, a young anaesthesiologist had a cardiac arrest after working 70 hours per week before the incident. More than 10 anaesthesiologists aged 30–45 yr had a cardiac arrest due to a heavy workload in China from 2013 to 2014.¹ Sadly, this number has been increasing in recent years.² The occupational status of anaesthesiologists was recently examined in a survey conducted by the New Youth Anaesthesia Forum, the largest web site of anaesthesiologists in China.³ The survey was also supported by the Chinese Society of Anaesthesiology and the Chinese Association of Anaesthesiology.

http://ift.tt/2s2qRhA

Premedication with salbutamol prior to surgery does not decrease the risk of perioperative respiratory adverse events in school-aged children

Abstract

Background: Perioperative respiratory adverse events (PRAE) remain the leading cause of morbidity and mortality in the paediatric population. This double-blinded randomized control trial investigated whether inhaled salbutamol premedication decreased the occurrence of PRAE in children identified as being at high risk of PRAE.Methods: Children with at least two parentally reported risk factors for PRAE undergoing elective surgery were eligible for recruitment. They were randomized to receive either salbutamol (200 µg) or placebo prior to their surgery and PRAE (bronchospasm, laryngospasm, airway obstruction, desaturation, coughing and stridor) were recorded.Results: Out of 470 children (6–16 yr, 277 males, 59%) recruited, 462 were available for an intention-to-treat analysis. Thirty-two (14%) and 27 (12%) children from the placebo and salbutamol groups experienced PRAE. This difference was not significant [odds ratio (OR): 0.83, 95% confidence interval (CI): 0.48–1.44, P: 0.51]. Oxygen desaturation [14/232 (6%) vs 14/230 (6%), OR: 1.01, 95% CI: 0.47–2.17, P: 0.98] and severe coughing [12/232 (5%) vs 10/230 (4%), OR: 0.83, 95% CI: 0.35–1.97, P: 0.68] were the most common PRAE, but did not significantly differ between the groups. The occurrence of PRAE was slightly lower in children with respiratory symptoms who received salbutamol compared with placebo [16/134 (12%) vs 21/142 (15%), OR: 0.93, 95% CI: 0.38–2.26, P: 0.87], but was not significantly different.Conclusions: Premedication with salbutamol to children aged between 6 and 16 years and at high risk of PRAE prior to their surgery did not reduce their risk of PRAE.Trial registration number: ACTRN12612000626864 (www.anzctr.org.au).

http://ift.tt/2s27mWy

ISO (Infraclavicular–SubOmohyoid) block: a single-puncture technique for diaphragm- and opioid-sparing shoulder anaesthesia

Editor—The shoulder joint and its muscles are entirely supplied by the brachial plexus and can be anaesthetized simply using the interscalene block. However, this proximal placement of local anaesthetic results in spread to many crucial neural structures (especially the phrenic nerve). To bypass this complication, distal block of the shoulder innervation is recommended.¹ Distally, the shoulder nerves are discrete, so multiple injections are usually required to achieve adequate analgesia. Blocking the axillary nerve and suprascapular nerve can provide adequate analgesia for minor shoulder surgery, but for major surgery both infraclavicular and suprascapular nerve blocks are required.¹ To minimize block time and patient discomfort, we perform both infraclavicular and suprascapular nerve blocks through a single-puncture technique (the ISO block).

http://ift.tt/2s2wyfq

Prolonged concurrent hypotension and low bispectral index (‘double low’) are associated with mortality, serious complications, and prolonged hospitalization after cardiac surgery

Abstract

Background: Low bispectral index (BIS) and low mean arterial pressure (MAP) are associated with worse outcomes after surgery. We tested the hypothesis that a combination of these risk factors, a 'double low', is associated with death and major complications after cardiac surgery.Methods: We used data from 8239 cardiac surgical patients from two US hospitals. The primary outcomes were 30-day mortality and a composite of in-hospital mortality and morbidity. We examined whether patients who had a case-averaged double low, defined as time-weighted average BIS and MAP (calculated over an entire case) below the sample mean but not in the reference group, had increased risk of the primary outcomes compared with patients whose BIS and/or MAP were at or higher than the sample mean. We also examined whether a prolonged cumulative duration of a concurrent double low (simultaneous low MAP and BIS) increased the risk of the primary outcomes.Results: Case-averaged double low was not associated with increased risk of 30-day mortality {odds ratio [OR] 1.73 [95% confidence interval (CI) 0.94–3.18] vs reference; P=0.01} or the composite of in-hospital mortality and morbidity [OR 1.47 (95% CI 0.98–2.20); P=0.01] after correction for multiple outcomes. A prolonged concurrent double low was associated with 30-day mortality [OR 1.06 (95% CI 1.01–1.11) per 10-min increase; P=0.001] and the composite of in-hospital mortality and morbidity [OR 1.04 (95% CI 1.01–1.07), P=0.004].Conclusions: A prolonged concurrent double low, but not a case-averaged double low, was associated with higher morbidity and mortality after cardiac surgery.

http://ift.tt/2s2qUKs

Lip, tooth, and pharyngeal injuries during tracheal intubation at a teaching hospital

Editor—A non-negligible number of patients suffer injury to the lips, teeth, or pharynx during tracheal intubation,¹² but the incidence of such injuries at teaching hospitals has not been clarified. This prospective observational study surveyed the occurrence of lip, tooth, and pharyngeal injuries associated with tracheal intubation by trainee doctors at a teaching hospital (Osaka Medical College, Japan) to compare incidence rates during the early and late training stages.

http://ift.tt/2tlkGJp

Insidious perforation of the rectum by a fallopian tube: the need to keep 'an open mind' when dealing with deep infiltrating endometriosis (DIE)

Endometriosis is a benign chronic disease which can have different degrees of severity and can potentially affect any organ. Intestinal endometriosis occurs in 3%â"37% of the cases, being more frequent in the rectosigmoid transition. Transmural involvement of intestinal endometriosis is extremely rare and is usually associated with recurrent abdominal pain. Due to the cyclical hormone influence, endometriosis implants may infiltrate the deeper layers of the intestinal wall and may lead to bowel obstruction or perforation. We present a case of transmural perforation of the rectum wall by an adjacent organ (left fallopian tube) that occurred insidiously in a patient with deep infiltrative endometriosis. A complete set of images is presented, regarding the preoperative, intraoperative and postoperative findings.

http://ift.tt/2t0doIA

Vibrio vulnificus tonsillitis after swimming in the Gulf of Mexico

Description

A 55-year-old man with decompensated cirrhosis secondary to Laennec's (alcoholic) cirrhosis and insulin-dependent diabetes mellitus presented with acute dysphagia and left-sided neck pain within hours of swimming in the Florida Gulf of Mexico. He did not ingest raw seafood, eat raw vegetables washed with fresh water or intentionally drink sea water prior to the presentation. He reported no gastrointestinal complaints. On examination, temperature was 39.1°C, and heart rate was 109 beats per minute with normal blood pressure. He appeared generally toxic and had an inflamed, ulcerated left tonsil; later, an axillary skin lesion developed with no trauma to the axillary area (figure 1). Neck CT showed submucosal tonsillar oedema, enlarged left palatine tonsil and reactive lymphadenopathy, consistent with acute tonsillitis (figure 2).

Figure 1

Tonsillar and pharyngeal lesions which appear ulcerated, inflamed and necrotic (A, B). Erythematous, slightly tender axillary lesion that appeared after the...

http://ift.tt/2sh0kS0

Acute cor pulmonale due to pulmonary tumour thrombotic microangiopathy from renal cell carcinoma

We report the case of a previously healthy man who presented with subacute dyspnoea after a long drive. He developed hypoxic respiratory failure, thought secondary to a massive pulmonary embolism and was treated with tissue plasminogen activator but died in the hospital despite aggressive medical measures. Autopsy revealed pulmonary tumour thrombotic microangiopathy (PTTM) from papillary renal cell carcinoma. PTTM is a rare clinicopathological syndrome that clinically results in symptoms of dyspnoea and right heart failure. Pathologically, a localised paraneoplastic process evolves from tumour microemboli in the pulmonary arterioles, resulting in fibrocellular proliferation and narrowing of the vessels, causing subacute right heart failure. To our knowledge, this is the first case of PTTM due to papillary renal cell carcinoma.

http://ift.tt/2t0xkuW

Mild androgen insensitivity syndrome (MAIS): the identification of c.1783C>T mutation in two unrelated infertile men

Two unrelated men complaining of primary male infertility presented to Orient Hospital in Damascus city. Physical examination showed moderate hypoandrogenic features. Both men were azoospermic. Hormone profiles revealed an elevation of follicle-stimulating hormone in one patient, but all the other hormones tested were within normal limits for both patients. Further genetic analyses, including karyotype and microdeletions in the AZF region of the Y chromosome, were normal in both patients. Mild androgen insensitivity syndrome was expected in the two patients. Sequencing analysis of the first exon in the androgen receptor (AR) gene have shown c.1783C>T mutation in the two patients with azoospermia. This paper sheds light on the need to screen for mutations in the AR gene, causing male infertility whenever mild hypoandrogenic features are present with unexplained male infertility.

http://ift.tt/2sh3l4O

Presacral mass in the setting of an ovarian cyst and abdominal pain

Tailgut cysts, also known as retrorectal hamartomas, are very rare neoplasms located in the presacral/retrorectal space that originate from the embryonic hindgut. Although a majority of lesions in this location are benign, 30% of the reported cases in the literature were found to be malignant. This report describes a case of a presacral mass found on CT of a 37-year-old woman who initially presented with worsening abdominal pain and a history of ovarian cyst rupture. This patient's clinical picture was complicated by an enlarging ovarian cyst. The risk of progression to malignancy warranted excision. She recovered well with resolution of her presenting symptoms. We report this case along with a brief review of the literature with a focus on the surgical considerations.

http://ift.tt/2t0dmQY

Spontaneous rupture of the bladder during vomiting

A 46-year-old woman with no urological history or comorbidities presented with an acute abdomen with haematuria after a spell of protracted vomiting. The initial cystogram was negative; however, CT imaging highly suggested an intraperitoneal bladder perforation, which was confirmed during laparotomy and subsequently repaired. Cystoscopic evaluation prior to laparotomy revealed no concurrent bladder pathology, and the ureteric orifices were intact. A cystogram 2 weeks after repair demonstrated no leaks, and her catheters were removed. She recovered well, with expectant postoperative pain and lower urinary tract symptoms settling on 3-month review. Spontaneous bladder rupture is a rare entity, with very few reports in the literature.

http://ift.tt/2sh3jtI

Successful repeat ECMO in a patient with AIDS and ARDS

Veno-venous extracorporeal membrane oxygenation (ECMO) is being more commonly used in patients with acute respiratory distress syndrome (ARDS) due to potentially reversible illnesses. Survival from ARDS using ECMO has been reported even in patients with AIDS. However, the indications for ECMO for ARDS due to immune reconstitution inflammatory syndrome (IRIS) in patients with AIDS are unknown. A 23-year-old man with AIDS and Pneumocystis jirovecii pneumonia was admitted to the intensive care unit with severe ARDS refractory to mechanical ventilator support requiring ECMO. Although ECMO was discontinued, a second treatment with ECMO was necessary due to IRIS-associated ARDS, resulting in an excellent patient outcome. This patient's clinical course suggests two important messages. First, ECMO is a reasonable option for the treatment of patients with ARDS even in a patient with AIDS. Second, ECMO may be effective for the treatment of patients with IRIS.

http://ift.tt/2t0thib

When your patient clicks: a loud clicking sound as a key sign to the diagnosis

A 19-year-old male patient was referred by his general practitioner with a new 'cardiac murmur'. For 1 week, he had been able to provoke a clicking sound, which was in time with his heart beat and originated from his chest. The physical examination and laboratory tests were normal. The sound was initially interpreted as most likely due to a valve condition such as mitral valve prolapse, but a transthoracic echocardiogram was normal. A cardiac CT was obtained, which showed left-sided ventral pneumothorax.

The Hamman's sign is a loud precordial pulse synchronous sound, which is often postural. It is pathognomonic for left-sided pneumothorax or pneumomediastinum. Hamman's sign as a presenting symptom is rare, but if present is key to diagnosis. The awareness of rare clinical findings is important and will prevent unnecessary diagnostic tests.

http://ift.tt/2sgC1Uk

Heroin-induced acute myelopathy with extreme high levels of CSF glial fibrillar acidic protein indicating a toxic effect on astrocytes

A man aged 33 years with previous heroin substance abuse was found unconscious lying in a bush. The patient had been without heroin for some time but had just started to use intravenous heroin again, 0.5–2 g daily. The patient had almost complete paraplegia and a sensory loss for all modalities below the mamillary level and a urine retention of 1.5 L. Acute MRI of the spine revealed an expanded spinal cord with increased intramedullary signal intensity, extending from C7–T9. The cerebrospinal fluid showed extremely high levels of nerve injury markers particularly glial fibrillar acidic protein (GFAP): 2 610 000/ng/L (ref. <750). The patient was empirically treated with intravenous 1 g methylprednisolone daily for 5 days and improved markedly. Very few diseases are known to produce such high levels of GFAP, indicating a toxic effect on astrocytes. Measuring GFAP could possibly aid in the diagnosis of heroin-induced myelopathy.

http://ift.tt/2t0yFle

Fever and asplenia: a dangerous association

Description

A 77-year-old splenectomised woman presented with temperatures reaching 38.5°C in the last 24 hours. The clinical presentation was non-specific and blood tests came back normal: a diagnosis of acute gastroenteritis was made. The patient's clinical state then deteriorated rapidly; she developed septic shock, acute renal failure, disseminated intravascular coagulation and purpura fulminans with peripheral necrosis of toes and fingers (figure 1 A,B), as complications of a pneumococcaemia. Following appropriate antibiotic therapy and supportive care, the patient recovered but had to undergo transmetatarsal and finger amputations(figure 1 C,D).

Figure 1

Necrosis of the (A) toes and (B) fingers in the context of disseminated intravascular coagulation. Clinical evolution following (C) transmetatarsal and (D) finger amputations.

Fever in patients with asplenia can be the initial, and sometimes sole, sign of a severe infection. It should never be trivialised. Moreover, other clinical...

http://ift.tt/2shdfDA

Giant lipoma of the hand causing median nerve compression

Lipomas are benign neoplasms derived from adipose tissue composed of mature adipocytes. They account for almost 50% of all soft-tissue neoplasms and occur in up to 2% of the population. They usually present asymptomatically as solitary discrete mobile lumps found most commonly on the neck, upper back, proximal limbs and chest. In less than 1% of cases, they can be found in the distal extremities.

We discuss the case of a 65-year-old man who presented with a 2-year history of a slowly enlarging left palm swelling, with recent-onset numbness and loss of power in the distribution of the median nerve. MRI studies showed that the 5x4x2.7 cm lipoma had a component extending into the distal aspect of the carpal tunnel, compressing the median nerve. It was successfully excised, and at follow-up the patient reported complete resolution of his symptoms.

http://ift.tt/2t0y57r

Urine fluorescence in antifreeze poisoning

Description

A 48-year-old man with diabetes mellitus and alcohol abuse presented to the emergency room (ER) with altered mental status, vomiting and abdominal pain. On examination, he was confused and uncooperative with a blood pressure of 70/40 mm Hg, heart rate of 66 beats/min, respiratory rate of 30 breaths/min and oxygen saturation of 95% on room air. Initial venous blood gas showed a 6.57 pH and PaCO₂ of 33 mm Hg. Laboratory investigation showed serum bicarbonate of 5 mEq/L, serum creatinine of 2.5 mg/dL (baseline creatinine 1.1 mg/dL), blood sugar of 200 mg/dL, anion gap of 29 mmol/L, delta ratio of 0.9, lactic acid of 21 mmol/L, a serum osmolality of 360 mOsm/kg and an osmolar gap of 44 mOsm; blood alcohol level was 0.053 g/dL, and urine was negative for ketones. Bedside examination of a urine samples (figure 1) and mouth under Wood's lamp showed blue–green fluorescence, which raised suspicion of ethylene glycol poisoning secondary to antifreeze ingestion. Serum level...

http://ift.tt/2sh8JEQ