Hypermucoviscous Klebsiella pneumoniae liver abscess requiring liver resection

Description 

A 41-year-old healthy woman from China presented to her local hospital with a 4-day history of fevers, malaise and epigastric pain. On examination, she had localised right upper quadrant abdominal pain on palpation. Laboratory investigations showed leukocytosis (13.8x10⁹/L), thrombocytopaenia (82x10⁹/L) and elevated alanine transaminase (184 U/L). An abdominal CT scan revealed a 10x8x9 cm multiloculated collection within the right liver lobe, with a second nodular septated collection under the left subcapsular region (figure 1). Her blood cultures returned positive for Klebsiella pneumoniae, resistant to ampicillin and susceptible to cefazolin, ciprofloxacin and meropenem. She was admitted to hospital and started on ceftriaxone.

Figure 1

Abdominal CT showing large multiloculated liver abscesses in segments 2/3 of the left liver lobe (white arrow) and segments 6/7 of the right liver lobe (black arrow).

Diagnostic and therapeutic ultrasound-guided 10F drains were inserted into both abscesses...

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Paediatric parapharyngeal ganglioneuroma

A 17-year-old man initially presented to his primary care physician with throat pain for 1 week and was started on amoxicillin. After four additional days of ongoing pain and difficulty swallowing with decreased oral intake, he presented to the emergency department. Exam showed fullness to the right posterior oropharynx and palpable mass in the right neck without stridor. Initial imaging was soft tissue neck CT with contrast, which showed cystic 8 cm mass in the parapharyngeal space. Patient additionally underwent MRI, which showed an 8.6 cm mass in the right posterior oropharynx with obliteration of the vallecula. Differential diagnosis included abscess; therefore, ear, nose, and throat (ENT) specialist was consulted for possible drainage. Intraoperatively, there was no abscess; alternatively a biopsy was obtained, which was identified by pathology as a ganglioneuroma. Patient was referred to paediatric ENT specialist, underwent extensive resection confirming diagnosis of ganglioneuroma and did well postoperatively.

https://ift.tt/2Plm0Em

Euglycaemic diabetic ketoacidosis in bariatric surgery patients with type 2 diabetes taking canagliflozin

A 52-year-old type 2 diabetic man previously on canagliflozin developed severe anion gap metabolic acidosis and markedly elevated beta-hydroxybutyrate on postoperative day (POD) 2 status post laparoscopic Roux-en-Y gastric bypass. An insulin drip and aggressive intravenous fluid repletion were initiated, and electrolytes were monitored and repleted. His anion gap closed, and he was discharged on POD 4. This euglycaemic diabetic ketoacidosis prolonged his hospital stay by 2 days.

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Bowel perforation in chronic idiopathic megarectum and megacolon

Description 

A 24-year-old man with autism spectrum disorder presented to accident and emergency complaining of a 1-week history of abdominal pain and diarrhoea. He had a history of chronic constipation with multiple previous admissions stretching 4 years back. On examination, he had a tender, distended abdomen with quiet bowel sounds. His CT scan on admission (figure 1) showed a dilated (up to 18 cm) rectum and sigmoid colon filled with faeces. The patient was managed conservatively with oral laxatives and regular enemas. However, the patient refused the enemas and was maintained on oral laxatives. Two days later, the patient complained of worsening abdominal pain. On examination, he had a peritonitic abdomen and reduced consciousness level. Biochemical investigations revealed worsening renal function and that the patient was now acidotic. A chest X-ray revealed free air beneath the diaphragm. A repeat CT scan (figures 2 and 3

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Asymptomatic dysphagia causing recurrent aspiration pneumonia

52-year-old male patient with known bipolar disorder and innate cerebral palsy causing widespread spasticity problems. Treated for 2 years with antidepressants and electroconvulsive therapy. He repeatedly presented with—and was treated for—pneumonia resulting in more than 20 episodes of hospital admission. He underwent numerous examinations until a diagnosis of dysphagia was established using video fluoroscopic swallowing examination (modified barium swallow). Eventually, as all other treatment regimens had proven effortless, percutaneous gastrostomy feeding tube was inserted and intensive training with a specialised occupational therapist was started. This treatment regimen caused the recurrent episodes of pneumonia to vanish. It is important to acknowledge that otherwise silent dysphagia may cause recurrent pneumonia.

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Trisomy 5 as the sole chromosomal anomaly in acute lymphoblastic leukaemia

Trisomy 5 as the sole cytogenetic aberration in acute lymphoblastic leukaemia (ALL) is exceedingly rare. As such, its prognostic and therapeutic relevance remains unknown. We report a case of an 18-year-old young man who was diagnosed with B cell ALL with trisomy 5 as the sole chromosomal abnormality. He was treated with chemotherapy and went into complete remission. On the 14th month of treatment, he relapsed with central nervous system involvement characterised by leukaemic infiltration of the optic nerve and facial palsy. He subsequently underwent reinduction chemotherapy with aggressive intrathecal chemotherapy followed by posterior globe and whole brain radiation therapy. He is currently on his 26th month of treatment, in second remission, with complete resolution of leukaemic infiltrative optic neuropathy and facial paralysis. As more cases of this nature are reported, we will be able to determine the relevance of this distinct cytogenetic entity.

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Colobronchial fistula: a rare cause of non-resolving pneumonia in Crohns disease

We discuss the case of a 44-year-old man with a refractory left lower lobe pneumonia progressing to a pulmonary abscess caused by a colobronchial fistula, a rare complication of underlying Crohn's disease. The patient presented with weight loss and signs of a pulmonary consolidation, which responded incompletely to the targeted antibiotic treatment. The causative colobronchial fistula was demonstrated by CT-guided puncture and retrograde injection of contrast medium. After fistula excision, the patient recovered rapidly with a weight gain of 4 kg within a few weeks.

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Charcot osteoarthropathy of the knee secondary to neurosyphilis: a rare condition managed by a challenging arthrodesis

The Charcot joint or neuropathic osteoarthropathy was first described as an arthritic sequela of neurosyphilis (tabes dorsalis). It results in significant joint destruction and instability. Nowadays, it is a very rare condition and represents a considerable challenge to the orthopaedic surgeon. The authors describe the case of a patient diagnosed with neurosyphilis who was requested an orthopaedic consultation for an enlarged and unstable knee. The diagnosis of Charcot knee was made and based on the clinical and radiographical findings combined with the patient's medical history. Knee arthrodesis was the surgical treatment chosen to preserve the limb and only succeeded at second attempt. At 4 years of follow-up, it proved to be an effective surgical treatment. In this article, we focus on the importance of early recognition of joint changes in these patients in order to prevent irreversible joint loss.

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Quadruple torsion of the fallopian tube in an 18-year-old virgin: a rare twist

In this report, we describe an 18-year-old nulliparous virgo, with no medical history, who presented herself at the emergency department with symptoms of lower abdominal pain and nausea with vomiting. On examination, an echogenic unilocular cyst with possible relation to the right ovary was found. The working diagnosis was an ovarian torsion. She underwent a diagnostic laparoscopy which revealed a quadruple torsion of the fallopian tube with hydrosalpinx. Detorsion of the tube was performed, and the tube was drained using diathermic incision. After the surgery, the patient recovered rapidly. Ultrasonic evaluation 38 days later showed an echogenic area measuring 2x3 cm suspected for persistent hydrosalpinx. Because of the asymptomatic postoperative period, the patient was treated conservatively, and no further treatment was performed.

https://ift.tt/2Lb9Z1a

Non-cutaneous AIDS-associated Kaposis sarcoma presenting as recurrent rectal abscesses

Kaposi's sarcoma is a fatal disease that typically presents with cutaneous manifestations in immunocompromised individuals. There are a small number of documented cases where patients diagnosed with this disease present without cutaneous lesions. We present a 35-year-old man with recurrent rectal abscesses and fistula-in-ano, which required multiple drainage procedures. Further investigation revealed a diagnosis of HIV-AIDS, and biopsy of a rectal mass confirmed the diagnosis of visceral Kaposi's sarcoma, despite the absence of cutaneous involvement. Workup revealed hepatic metastasis and a second pulmonary primary malignancy. The patient denied chemotherapy or further intervention and was subsequently lost to follow-up. Prompt diagnosis of Kaposi's sarcoma and initiation of treatment is vital to decrease disease progression. A high index of suspicion should be present in immunocompromised patients, and clinicians must recognise atypical presentations in order to improve long-term survival.

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Primary amelanotic malignant melanoma of cervix masquerading as squamous cell carcinoma presenting with extensive metastases

Amelanotic melanoma of cervix is a rare and aggressive neoplasm and only few cases have been reported in the literature. We report a rare case of an amelanotic melanoma of the uterine cervix with extensive metastases and multiple subcutaneous nodules. Due to the unusual site and amelanotic nature of the lesion, chances of misdiagnosis are high and immunohistochemical markers for melanoma help establish the diagnosis. The possibility of metastasis from a primary malignant melanoma of the skin needs to be ruled out. The present case was initially misdiagnosed and treated on the regimen for squamous cell carcinoma, but progressed despite chemotherapy. After a thorough re-evaluation and applying extensive panel of immunohistochemistry, the diagnosis of an amelanotic malignant melanoma of uterine cervix was established.

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Internal iliac artery transposition for vascular reconstruction in a patient with life-threatening iatrogenic common iliac artery injury

Major vascular injury during surgery is life threatening and can be a nightmare for any surgeon.

We share our experience of a 42-year-old woman where right common iliac artery and both common iliac veins were accidentally injured during lumbar discectomy leading to haemorrhagic shock. Patient was resuscitated and explored. A 4 cm segment of right common iliac artery was found lacerated along with perforations of both iliac veins. Proximal segment of internal iliac artery was mobilised quickly and vascular continuity was restored by end-to-end anastomosis of this segment to the proximal segment of common iliac artery after excising the damaged segment. Iliac veins were repaired primarily. Patient made an uneventful recovery. We share this technique as it was found expeditious and effective and may benefit surgeons working in this field.

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Fever in a returning traveller: visceral leishmaniasis triggering haemophagocytic lymphohistiocytosis

We present the case of a 23-year-old student admitted with fever, night sweats and splenomegaly. These non-specific signs and symptoms posed a diagnostic challenge which was further complicated by a history of recent foreign travel. The range of potential diagnoses required a variety of investigations in order to reach the final diagnosis. The incidental finding of an incompetent bicuspid aortic valve and an inflamed gallbladder further clouded the diagnostic process. Despite treatment with broad spectrum antibiotics, the patient continued to deteriorate. Serological testing finally provided a diagnosis of visceral leishmaniasis. The patient subsequently developed haemophagocytic lymphohistiocytosis, a life-threatening immune hyperactivity state that very rarely complicates leishmaniasis infection. With the use of amphotericin B and high-dose steroids, the patient made an excellent recovery.

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Progressive supranuclear palsy responding to intravenous thiamine: superimposed Wernickes encephalopathy?

Progressive supranuclear palsy (PSP) may be a risk factor for thiamine deficiency. The classic symptoms of PSP (postural instability, supranuclear vertical gaze palsy and dementia) overlap with the clinical triad of Wernicke's encephalopathy (cognitive impairment, gait problems and ocular abnormality). Therefore, superimposed thiamine deficiency in patients with PSP may aggravate the pre-existing symptoms of PSP. Here, we are reporting a 64-year-old woman having supranuclear ocular palsy, gait instability and dementia for the past 2–3 years. The patient fulfilled the diagnostic criteria of PSP. In parallel, she fulfilled the Caine's criteria of Wernicke's encephalopathy. Her serum thiamine level was low. Supplementation of thiamine led to marked improvement in the symptoms which had been present for many years. These symptoms were originally presumed to be due to PSP. This case highlights the needs to identify superimposed thiamine deficiency in patients with PSP.

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Multiple renal calculi due to hypercalcaemia induced by over-the-counter vitamin D intoxication

Renal stone disease is a common and painful condition. Even though it is rarely fatal, patients describe it as the worst pain in their life. While dietary calcium may decrease the risk of stone formation, patients on supplemental calcium are at higher risk. Moreover, patients with diabetes are more prone to develop renal calculi. Hypervitaminosis D is a rare cause of hypercalcaemia. This is a case of an elderly diabetic man who developed multiple calcium oxalate renal stones due to hypercalcaemia following calcium–vitamin D supplementation.

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Misplaced Foley catheter in ureter in a female with neurogenic bladder: a rare complication report

Accidental placement of Foley catheter in ureter is a rare phenomenon. It is more common in females with neurogenic bladder who have hypocontractile bladder or there can be iatrogenic placement during surgical procedures. We describe a case of a female suffering from upper motor neuronal lesion due to trauma at T8 level (American Spinal Injury grade A) following which she developed neurogenic bladder. A Foley catheter was unintentionally placed in the ureter and subsequently removed through a novel technique of percutaneous ultrasound-guided balloon puncture. It is not only imperative to diagnose and manage such an aberrant Foley catheter placement but also more importantly proper steps must be taken to prevent such a complication from occurring in these patients.

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Mediastinal metastasectomy from a primary germ cell testicular tumour resulting in occult thoracic duct injury and chylothorax

A 22-year-old man underwent mediastinal metastasectomy for a testicular germ cell tumour via median sternotomy. Intraoperatively, the tumour was massive, measuring 88 mm in anterior-posterior (AP) diameter. It was densely adherent to the trachea and aggressive debulking resulted in tracheal injury. Therefore, the patient was kept nil by mouth for 3 days postoperatively and was discharged uneventfully. He represented only 2 days later with a large right-sided chylothorax. His chylothorax was managed conservatively with insertion of an intercostal catheter (ICC) and a low-fat diet. Over the course of 9 days, the ICC drained approximately 5 L of fluid. His admission was further complicated by severe gastroparesis requiring feeding Nasojejunal (NJ) tube placement. The delayed feeding in this case resulted in late detection of the occult thoracic duct injury. This case illustrates that conservative and multidisciplinary management of a postoperative chylothorax from a suspected thoracic duct injury achieves favourable outcomes avoiding further surgical intervention.

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Malignant proliferating trichilemmal tumour

Proliferating trichilemmal tumours are benign but locally aggressive skin neoplasms arising from hair follicles. Rarely, they can become malignant and must be appropriately managed to prevent recurrence and metastasis. One must have a low threshold for diagnosing this rare neoplasm.

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Tracking a painful episode after a joint replacement using patient-reported outcome measures (PROMs)

Patient-reported outcome measures (PROMs) are an important tool in measuring the benefit of a surgery for patients and for clinicians. The results of such assessment tools can be used to monitor patient progress or initiate intervention. The scores also provide a reproducible evaluation of functional recovery and well-being after surgery. We report the case of a 68-year-old woman who underwent left unicondylar knee replacement in November 2011 followed by right unicondylar knee replacement in April 2012. Prospective, web-based electronic PROMs were used preoperatively and every 6–12 months postoperatively to monitor the improvement in pain and function symptoms. These outcome measures were beneficial in helping to monitor an episode of new pain in her left knee, without requiring invasive or extensive investigation.

https://ift.tt/2PnEUdI

Delirium and topographical disorientation associated with glioblastoma multiforme tumour progression into the isthmus of the cingulate gyrus

Since there is no cure for glioblastoma multiforme (GBM), the goal of treatment becomes prolonging the survival through cytoreduction while minimising neurological deficits. In this case report, laser interstitial thermal therapy (LITT) was used once the tumour progressed into the isthmus of the cingulate gyrus. One year after temporal lobectomy, disorders of memory, emotion, personality and navigation, likely related to limbic system involvement along with hallucinations and fluctuating cognition occurred as the tumour progressed. After ablation of the posterior cingulum, worsening of topographical disorientation was observed.

Per literature review, delirium has been noted in patients with strokes involving the right-sided temporo-parieto-occipital junction, and topographical disorientation has been associated with lesions of the right posterior cingulum. Alternative causes of these deficits were ruled out, leaving structural changes as the primary explanation. This is the first report of the neurological deficits associated with tumour progression and vasogenic oedema in this region.

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Exceptional mucocutaneous manifestations with amyloid nephropathy: a case report

Amyloidosis is a very rare disease that is difficult to diagnose because of the unspecific early clinical manifestations of the disease. Accurate and early diagnosis is extremely important because the effect o...

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Neural therapy of an athlete’s chronic plantar fasciitis: a case report and review of the literature

The focus of this case report is on the role of inflammation as a contributor to pain in plantar fasciitis and its cure by the injection of local anesthetics.

https://ift.tt/2MGLRbe

Conventional cardiopulmonary resuscitation-induced refractory cardiac arrest due to latent left ventricular outflow tract obstruction due to a sigmoid septum: a case report

Patients with left ventricular outflow tract obstruction who do not exhibit a dynamic pressure gradient at rest, experience pressure gradient increases of ≥ 30 mmHg only during specific situations; this is cal...

https://ift.tt/2BwHyes

The challenges of treating tracheobronchitis in a laryngectomee due to nontypeable Haemophilus influenzae: a case report

Laryngectomees run the risk of developing severe respiratory tract infections especially during the winter and when they do not wear a stoma cover. A case of severe tracheobronchitis in a laryngectomee is pres...

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Inflammatory fibroid polyps of the appendix: different presentation and literature review

Abstract

Inflammatory fibroid polyps (IFPs), or Vanek's tumor, are rare benign mesenchymal lesions of the gastrointestinal tract (GIT). IFPs can be found throughout the GIT but most frequently in gastric antrum or ileum, with the appendix accounting for only <1% of all IFPs. The clinical presentation is usually vague yet depends on the location. We report a case of 50-year-old healthy male presented to the emergency department with a sub-acute complaint of non-specific abdominal pain, which was suspected to be appendicitis. Abdominal CT scan was done as well as colonoscopy and histopathology were scheduled. A week later, he presented in the clinic, still complaining of abdominal pain; thus, the decision was made to schedule him for laparoscopy with appendectomy. Finally, the post-operative course was unremarkable and the patient was discharged home. This is a rare case of IFPs originating in the appendix presenting as an atypical sub-acute appendicitis.

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Frontal lobe intracerebral schwannoma mimicking metastatic lesion in a patient with papillary thyroid carcinoma

Abstract

Intracerebral schwannomas are quite rare. Due to their rarity and lack of pathognomonic imaging features, intracerebral schwannoma may be overlooked in the initial differential diagnosis of an intra-axial mass with heterogeneous ring enhancement, such as a high-grade glioma, metastasis or lymphoma. Here, we present a 21-year-old woman with prior diagnosis of papillary thyroid carcinoma and recent history of seizures who had a heterogeneously ring-enhancing left frontal lobe mass. Our presumptive diagnosis was a metastatic tumor since she had a history of thyroid cancer. Because of uncertainty in preoperative differential diagnosis, the decision was made to proceed with excisional biopsy of the tumor via craniotomy. She underwent uneventful gross total resection of the tumor that histopathology revealed as an intracerebral schwannoma.

https://ift.tt/2OQTzND

Post-nephrectomy diaphragmatic hernia. Increase suspicion and decrease morbi-mortality: two cases report

Abstract

Post-nephrectomy diaphragmatic hernia is an extremely rare condition. The symptoms may be acute or latent and will depend on the herniated organ, which makes it difficult to suspect. Therefore, it is necessary to know about this type of iatrogenic hernia to avoid a delay in diagnosis. A radiological confirmation with computed tomography and early surgical treatment greatly decreased the morbidity and mortality. We report two cases: a 76-year-old male, who underwent a right nephrectomy 18 days prior due to a renal carcinoma; and a 59-year-old woman, who underwent the procedure 4 years prior due to left renal atrophy.

https://ift.tt/2vX55Qx

High-grade chondrosarcoma of the larynx: a case report and literature review

Abstract

A 64-year-old male presented with a 2-month history of sudden onset dysphonia. Endoscopic evaluation of the larynx revealed a complete right vocal cord palsy. Computed tomography of the neck revealed a mass medial to the right thyroid associated with the cricoid cartilage. Histologic examination confirmed high-grade chondrosarcoma. The patient underwent right-sided hemicricoidectomy with tracheal flap reconstruction, right thyroid lobectomy and partial oesophagectomy with primary anastomosis followed by adjuvant radiation therapy. He is currently being followed as an outpatient with no evidence of disease. High-grade chondrosarcoma of the larynx is an exceedingly rare tumour, associated with a poor prognosis. Current best evidence suggests primary surgical resection with negative margins. There is a lack of evidence to guide post-operative management of high-grade chondrosarcoma. They have a poor prognosis following surgical resection and a 10-year survival rate of 29%.

https://ift.tt/2OQKpRk

Intra-operative identification of a De Garengeot hernia: a rare finding and discussion of operative approach

Abstract

The presence of an incarcerated vermiform appendix within a femoral hernia defect, a De Garengeot hernia, is distinctly different than an inguinal hernia containing the appendix, an Amyand hernia. The De Garengeot hernia is a rare finding with few reported cases. We present a 35-year-old female with a painful groin mass palpable below the inguinal ligament. An ultrasound of the groin revealed a thin-walled fluid collection medial to the femoral vessels. No additional imaging at the time was obtained. Intra-operatively, the patient was found to have her distal appendix incarcerated within the transected hernia sac thus altering the planned surgical procedure. We present a unique operative approach for managing a De Garengeot hernia.

https://ift.tt/2vZQVOt

Small, incidental hepatic epithelioid haemangioendothelioma the role of ablative therapy in borderline patients

Abstract

Primary hepatic epithelioid hemangioendothelioma (HEHE) is an extremely rare tumor of vascular origin with an incidence of <0.1 per 100 000 population. We describe a 70-year-old man with renal cell carcinoma managed via robotic right partial nephrectomy who was also found to have a solitary 10 mm lesion on a pre-operative staging computer tomography (CT) scan. The patient underwent percutaneous biopsy and local ablation of the lesion consistent with an epithelioid hepatic haemangioendothelioma. Post-procedure CT scan after 1 month showed adequate ablation margins with no new lesions. The role of local ablation for solitary, small HEHE is discussed.

https://ift.tt/2ORNkJA

A case of spontaneous hemopneumothorax in which the condition worsened after chest drainage

Abstract

A 45-year-old woman was referred to our hospital with sudden chest pain. She came on foot with normal vital signs. Computed tomography (CT) revealed right mild pneumothorax with niveau level. We suspected spontaneous hemopneumothorax (SHP) and inserted a thoracic drain. After 800 ml of blood and air was evacuated immediately, the outflow from the drain stopped. However, despite the outflow of blood from the drainage tube having stopped, she developed hemorrhage shock 2 h after drainage. Contrast-enhanced CT revealed extra-vascular signs at the top of the right pleural cavity. Emergency video-assisted thoracic surgery (VATS) was performed. We identified the chest drain as being obstructed by blood clot. Continuous bleeding from a small aberrant vessel at the top of the thoracic cavity was identified, and we stanched it easily by clipping. The present experience suggests that routine enhanced CT and aggressive emergent VATS should be performed in cases of SHP.

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Assessing changes in tissue oxygenation by near-infrared spectroscopy following brachial plexus block for arteriovenous fistula surgery: A prospective observational pilot study

BACKGROUND Near-infrared spectroscopy (NIRS) can be used to measure tissue oxygen saturation (StO2) in different sites and in a wide range of clinical scenarios. Peripheral regional anaesthesia induces vascular changes causing increased arterial blood flow and venodilatation, but its effect on StO2 is still under debate. This is especially so for patients undergoing arteriovenous fistula surgery, wherein latest data suggest an improved outcome under brachial plexus block (BPB) compared with local anaesthesia, but no data are available. OBJECTIVE The aim of this study was to investigate changes in StO2 following BPB prior to arteriovenous fistula surgery using NIRS. DESIGN A pilot study. SETTING A secondary teaching hospital from August 2016 to March 2017. PATIENTS Fifteen patients undergoing arteriovenous fistula surgery. INTERVENTION Ultrasound-guided BPB in 15 patients undergoing arteriovenous fistula surgery. OUTCOME MEASURES StO2 at baseline and compared with baseline and the contralateral arm following BPB measured using NIRS of the thenar eminence (NIRSth). RESULTS Baseline values of StO2 assessed by NIRSth were 42.6 ± 7.7% in the arteriovenous fistula arm and 42.7 ± 9.7% in the contralateral arm. There was no significant difference between the two. Five minutes after BPB, there was a significant increase in StO2 of the blocked arm, compared with the control arm expressed as difference of absolute values (7.1 ± 9.7%). At 60 min, an absolute difference of 21.0 ± 13.5% was reached. The absolute increase in StO2 of the blocked arm compared with baseline reached significance after 5 min (8.8 ± 4.6%) and increased up to 23.2 ± 8.2% after 60 min. CONCLUSION NIRSth indicates that BPB significantly increases StO2 of the arteriovenous fistula arm in patients undergoing haemodialysis. TRIAL REGISTRY NUMBER (S) Clinicaltrials.gov: NCT03044496 Correspondence to Dr Jonas Keuler, MD, Department of Anaesthesiology and Intensive Care Medicine, Marienhospital Stuttgart, Böheimstraße 37, Stuttgart 70199, Germany Tel: +49 711 6489 2716; e-mail: jonas.d.keuler@gmail.com © 2018 European Society of Anaesthesiology

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Peri-operative respiratory adverse events in children with upper respiratory tract infections allowed to proceed with anaesthesia: The French national study

BACKGROUND Peri-operative respiratory adverse events (PRAEs) in paediatric patients with upper respiratory tract infections (URTIs) remain inadequately explored in patients allowed to proceed to anaesthesia and surgery. OBJECTIVE To determine the incidence and risk factors of PRAE in children with URTI allowed to proceed to anaesthesia. DESIGN Multicentre cohort study performed over 6 months in France. SETTING Sixteen centres with dedicated paediatric anaesthetists. PATIENTS Eligible patients were aged from 0 to 18 years with URTI symptoms on admission or a history of such over the preceding 4 weeks. MAIN OUTCOMES The primary outcome of the study was to determine predictors of PRAE. Secondary outcomes were: predictors of peri-operative arterial desaturation and of the decision to proceed with anaesthesia and surgery in children with URTI. RESULTS Overall, 621 children were included and 489 (78.7%) anaesthetised. Of those anaesthetised, 165 (33.5%) and 97 (19.8%) experienced PRAE and arterial desaturation, respectively. Factors predictive of PRAE included patient age, tracheal intubation and the absence of midazolam premedication. Factors predictive of peri-operative arterial desaturation included patient age, anaesthetist experience, endoscopic procedures and the presence of other PRAE. Factors predicting proceeding to anaesthesia in the context of URTI included anaesthetist experience, emergency procedures and the absence of severe URTI symptoms. CONCLUSION The risk of PRAE in patients anaesthetised in the presence of URTI was similar to previous publications – close to 30%. In the light of our findings, first, current rescheduling indications should be questioned, and second, further medical and organisational strategies should be investigated to reduce PRAE in children with URTI. TRIAL REGISTRATION The study was registered in the European Networks of Centers for Pharmacoepidemiology and Pharmacovigilance (EUPAS16436). Correspondence to Souhayl Dahmani, MD, PhD, Department of Anaesthesia and Intensive Care, Robert Debre University Hospital, Assistance Publique-des Hôpitaux de Paris, 48 Boulevard Serurier, 75019 Paris, France Tel: +00 33 1 40 03 41 83; fax: +00 33 1 40 03 20 00; e-mail: souhayl.dahmani@rdb.aphp.fr Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (https://ift.tt/2ylyqmW). © 2018 European Society of Anaesthesiology

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Dexmedetomidine mitigates sevoflurane-induced cell cycle arrest in hippocampus

Abstract

Background

Epidemiologic studies suggest the possibility of a modestly elevated risk of adverse neurodevelopmental outcomes in children exposed to anesthesia during early childhood. Sevoflurane is widely used in pediatric anesthetic practice because of its rapid induction and lower pungency. However, it is reported that sevoflurane leads to the long-term cognitive impairment. Some evidence revealed that the selective α2-adrenoreceptor agonist dexmedetomidine (DEX) exerts neuroprotective effects in various brain injury models of animals. But the role of DEX on sevoflurane-induced neuro-damage remains elusive.

Materials and methods

In our study, we isolated the hippocampal neuron cells from newborn neonatal rats and verified the purity of neurons by immunocytochemistry. We employed the flow cytometry and western blot to examine the effect of sevoflurane, DEX and α2-adrenergic receptor antagonist yohimbine on cell cycle distribution.

Results

Immunocytochemistry results showed the purity of neurons > 94%, which provided a good model for neural pharmacology experiments. The exposure of sevoflurane-induced cell cycle arrest at S phase and suppressed the expression of brain-derived neurotrophic factor (BDNF) and tyrosine kinase B (TrkB). The addition of DEX suppressed sevoflurane-induced cell cycle arrest and the inhibitory of BDNF and TrkB expression. But the function of DEX was partly blocked by a α2 adrenergic receptor blocker yohimbine.

Conclusion

Sevoflurane suppressed neuron cell proliferation via inhibiting the expression of BDNF and TrkB, and DEX relieved the neurotoxicity induced by sevoflurane via α2 adrenergic receptor. These findings provided new evidence that DEX exerted as a neuroprotective strategy in sevoflurane-induced neuro-damage, and provided new basis for the clinical application of DEX.

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The tendinous septum of the semispinalis capitis muscle spatially separates the dorsal ramus between C3 and C4

Abstract

Local anesthetic injection into the medial head of the semispinalis capitis muscle can anesthetize the greater occipital nerve (GON) and third occipital nerve (TON) simultaneously (greater and third occipital nerve block: GTO block). Alternatively, inter-semispinal plane (ISP) block can anesthetize the dorsal rami of the cervical spinal nerves from C4 to T4. The GON, TON, and the dorsal rami of the inferior level cannot be blocked with a single injection. To elucidate this phenomenon from an anatomical standpoint, we performed an ISP block either alone or with a GTO block using water-based acrylic dye in three thiel-embalmed cadavers. Both dyes were clearly separated by the tendinous septum running obliquely inside the semispinalis capitis muscle (SCA). The tendinous septum of the SCA may have a relatively strong connection with the dorsal edge of the semispinalis cervicis muscle, and this structure may stem the injectate spread. Therefore, the GON and TON, running through the medial head of the SCA, and the dorsal rami of the inferior level are spatially separated by the tendinous septum, and cannot be blocked with a single injection.

https://ift.tt/2vZliEJ

Echo-guided invasive pain therapy: indications and limitations

Purpose of review The purposes of this review are to summarize the advantages and limitations of ultrasound-guided pain interventions, and to illustrate those interventions with peripheral, axial and musculoskeletal pain procedures. Recent findings With the capability of locating the interfascial plane, ultrasonography has led to the emergence of a series of plane blocks for the thoracoabdominal region in the recent decade. Ultrasonography for musculoskeletal procedures has been of growing interest because of the major advantage of direct visualization and scanning of various soft tissues and real-time spread in the injectate, thereby enhancing precision and efficacy, reducing risk of trauma and avoidance of radiation. For spine and intra-articular structures, ultrasonography is complicated by the bony shadow artefact and often deep location of the structure, making acquisition of ultrasound image challenging. Despite these difficulties, there is growing interest in applying ultrasonography for cervical spine and sacroiliac joint procedures. Summary Pain intervention under ultrasound guidance is particularly valuable in peripheral and musculoskeletal procedures. There is growing interest of its application in cervical spine and sacroiliac joint. More outcome studies are required in the future to make ultrasound-guided pain intervention as the established procedure. Correspondence to Philip Peng, MBBS, FRCPC, Founder (Pain Medicine), Department of Anesthesia and Pain Medicine, University of Toronto, University Health Network-Toronto Western Hospital, McL 2-405, 399 Bathurst Street, Toronto, ON, Canada M5T 2S8. Tel: +1 416 603 5118; fax: +1 416 603 6494; e-mail: Philip.peng@uhn.ca Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Drug selection for ambulatory procedural sedation

Purpose of review Ambulatory procedural sedation is used to relieve anxiety, pain and discomfort in a broad spectrum of patients during many types of diagnostic or therapeutic procedures. This review focuses on recent comparative studies of commonly used and new drugs for adult ambulatory sedation. Recent findings Midazolam and propofol are commonly used for ambulatory sedation. Their pharmacological properties offer many advantages and there is much experience with their use. Ketamine can be a useful addition to hypnotic drugs but the advantage of the use of ketofol (a mixture of propofol and ketamine) is, although often practiced, difficult to assess. Dexmedetomidine is a relatively new sedative drug and many studies suggest advantages. New findings about its effects, however, show that the hemodynamic consequences of the use of dexmedetomidine may last for several hours. New sedative drugs for procedural sedation are still being developed: remimazolam has many properties that would make it an ideal sedative and has been studied in a phase 3 study. Summary The properties that would constitute the ideal sedative have yet to be combined in one drug. The selection of the drugs used for ambulatory sedation depends on many factors such as procedure type, patient characteristics and the expectations of patients and the healthcare provider. Because of this, the literature cannot yet provide a definitive answer to the question which drug is best selected in a specific situation. Correspondence to Clemens R.M. Barends, MD, Department of Anaesthesiology, University of Groningen, University Medical Centre Groningen, P.O. Box 30001, 9700 RB Groningen, The Netherlands. Tel: +31 50 361 6161; e-mail: c.r.m.barends@umcg.nl Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Rebound pain after regional anesthesia in the ambulatory patient

Purpose of review Regional anesthesia is popular in ambulatory setting allowing safe and fast recovery. The problem of 'rebound pain', that is very severe pain when peripheral nerve block (PNB) wears off represents a clinically relevant problem and a cause of increased healthcare resource utilization. This review tries to make the point on a not so rare, unwanted and often neglected side effect of PNB. Recent findings The major finding is the lack of large prospective studies. Incidence of rebound pain is unknown but could reach 40% of patients at PNB resolution. To date, pathophysiological mechanisms remain debated: mechanical and chemical (proinflammatory effect of local anesthetics) nerve insult caused by PNB in predisposed patients (with severe preoperative pain, younger patients). Effective preventive strategies also are missing (e.g. role of analgesic adjuvants in PNB). Long-term consequences in term of functional recovery and persistent pain have not been demonstrated. Interview of patients has underlined the need of information and education about PNB and postoperative analgesia. Summary Patients' report of excruciating pain and major distress when PNB wears off questions the quality of current anesthesia practice in ambulatory setting. Rebound pain unanswered questions are challenging in the area of perioperative medicine. Correspondence to Patricia Lavand'homme, MD, PhD, Department of Anesthesiology, Cliniques Universitaires St Luc – University Catholic of Louvain, Av Hippocrate 10, B-1200, Brussels, Belgium. Tel: +32 2 764 18 21; fax: +32 2 764 36 99; e-mail: patricia.lavandhomme@uclouvain.be Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Neuromonitoring in the ambulatory anesthesia setting: a pro–con discussion

Purpose of review Various neurologically focused monitoring modalities such as processed electroencephalography (pEEG), tissue/brain oxygenation monitors (SbO2), and even somatosensory evoked responses have been suggested as having the potential to improve the well tolerated and effective delivery of care in the setting of outpatient surgery. The present article will discuss the pros and cons of such monitors in this environment. Recent findings There is a paucity of evidence from rigorous, well designed clinical trials demonstrating that the routine use of any neuromonitoring technique in an ambulatory surgery setting leads to meaningful cost savings or a reduction in morbidity or mortality. Summary The use of advanced neuromonitoring techniques (primarily pEEG) may be considered reasonable in two instances: for the prevention of intraoperative awareness during the administration of total intravenous anesthesia coupled with the use of a neuromuscular blocking drug, and for the prevention of relative drug overdose (and possibly postoperative delirium) in the elderly. Correspondence to Peter A. Goldstein, MD, C.V. Starr Laboratory for Molecular Neuropharmacology, Department of Anesthesiology, Weill Cornell Medicine, 1300 York Avenue, Room A-1050, New York, NY 10065, USA. Tel: +1 212 746 5325; fax: +212 746 4879; e-mail: pag204@med.cornell.edu Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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