Mircea Mureșan, Simona Mureșan, Ioan Balmoș, Daniela Sala, Bogdan Suciu and Arpad Torok
Despite recent advancements in antibiotic therapy and the progress made in critical care and modern diagnostic methods, acute mediastinitis continues to be a severe condition.
Diagnosis and treatment
Acute mediastinitis can occur in the context of cardio-thoracic surgery, oesophageal perforations and oropharyngeal infections condition. Forty-five percent of oesophageal perforations occurs during simple endoscopy. Spontaneous perforation (Boerhaave syndrome) accounts for 15% of perforations, and twelve percent are due to the ingestion of foreign bodies. Other causes include blind or penetrating trauma, and circa 9% to intraoperative lesions. CT scan is the standard investigation that reveals direct signs of mediastinitis.
The oral administration of contrast substances can underscore the level of oesophageal perforation. Conservative treatment is the first-choice treatment and surgical treatment is reserved only for specific situations.
The principles of surgical treatment consist of drainage, primary suture, oesophageal exclusion with or without the application of oesophagectomy, endoscopic vacuum wound assisted therapy of the perforation and associated paraoesophageal mediastinal drainage and endoscopic stenting associated with drainage.
The lowest mortality rate is recorded in patients with perforations diagnosed less than twenty-four hours after the onset of symptoms. Surgical treatment remains the gold standard especially in cases of thoracic and abdominal perforations while further investigations are mandatory before endoscopic stenting is carried out.
Yingke He, John Ong and Sharon Ong
Lactic acidosis (LA) is a complication of diseases commonly seen in intensive care patients which carries an increased risk of mortality. It is classified by its pathophysiology; Type A results from tissue hypo-perfusion and hypoxia, and Type B results from abnormal metabolic activity in the absence of hypoxia. Reports of the co-occurrence of both types have been rarely reported in the literature relating to intensive care patients. This case report describes the challenging management of a patient diagnosed with both Type A and Type B LA.
A 55-year-old female with newly diagnosed diffuse large B-cell lymphoma (DLBCL) developed hospital-acquired pneumonia, respiratory failure, shock and intra-abdominal septicaemia from a bowel perforation. Blood gases revealed a mixed picture lactic acidosis. Correction of septic shock, respiratory failure and surgical repair caused initial improvement to the lactic acidosis, but this gradually worsened in the intensive care unit. Only upon starting chemotherapy and renal replacement therapy was full resolution of the lactic acidosis achieved. The patient was discharged but succumbed to her DLBCL several months later.
Type A and Type B LA can co-occur, making management difficult. A systematic approach can help diagnose any underlying pathology and aid in early management.
Neha Gupta and Chrystal Rutledge
Pyruvate dehydrogenase complex deficiency (PDCD) is a rare neurodegenerative disorder associated with abnormal mitochondrial metabolism. Structural brain abnormalities are common in PDCD. A case of a patient with PDCD with an unusual presentation is described. A 20-month-old boy with hypotonia and developmental delay, presented with hypoxia and respiratory distress due to bronchiolitis. During hospitalisation, he was prescribed PediaSure® feeds. Two days after starting these feeds, he developed respiratory arrest requiring intubation. His blood gas before arrest revealed lactate of 8.9 mmol/L despite normal haemodynamics. After stabilisation and a period of compulsory fasting, subsequent feeding with PediaSure® resulted in the recurrence of lactic acidosis. A metabolic workup revealed an elevated serum pyruvate level. Brain MRI was normal. Skeletal muscle biopsy confirmed PDCD. The most common cause of PDCD is a mutation in the X-linked PDHA1 gene. The severity of PDCD can range from neonatal death to more delayed onset of symptoms as in our index case. Normal brain MRI is reported in only 2% of patients with PDCD. There is no effective treatment for PDCD. In patients with proximal muscle weakness and feeding intolerance with glucose-containing feeds, the presence of lactic acidosis should raise the suspicion of PDCD irrespective of the patient's age and normal MRI.
Phlegmasia cerulea dolens (PCD) is a severe, rare complication of deep vein thrombosis, which is characterised by compartment syndrome, arterial compromise, venous gangrene, and shock. Prothrombotic states are the primary risk factor for PCD, which, in most cases, is associated with pulmonary embolism and carries a high mortality.
A 46-year-old male presented following a pulseless electrical activity (PEA) arrest due to saddle pulmonary embolism (PE). He subsequently developed PCD and venous gangrene secondary to inferior vena cava obstruction, in the setting of a new diagnosis of testicular germ cell tumour.
PEA arrest, as the initial presenting problem in malignancy, is rare. It is extreme for the first indication of cancer to be a PEA arrest from massive PE. While hypoxic brain injury from the cardiac arrest precluded intervention in this case, a surgical approach entailing en bloc resection of aortocaval metastasis, with subsequent IVC reconstruction, followed by lower limb venous thrombectomy would have been favoured as it was considered that an endovascular approach would not have been successful.
A case of a patient with phlegmasia cerulea dolens secondary to testicular cancer, who presented following PEA arrest is described.
Cristina Petrișor, Sebastian Trancă, Andreea Cordoș and Vasile Bințințan
Patient-controlled analgesia with morphine is routinely used for postoperative pain management. Due to the safety profiles of the technique, which are patient/disease related or technique/equipment related, severe respiratory depression requiring opioid antagonists or airway management are uncommon.
The case of a patient with right colon carcinoma who was operated on for hemicolectomy under general anaesthesia and who presented with apnoea, after postoperatively receiving an initial bolus of 1mg of morphine. A large post-traumatic porencephalic cyst of the left brain hemisphere, previously undiagnosed, was found on the computed tomography scan. We excluded human errors, technique and equipment factors, and the patient did not have any other predisposing conditions like sleep apnoea, obesity, recent head injury or concurrent use of other sedatives. Previously the patient had been entirely asymptomatic, and her increased susceptibility to respiratory depression was the only clinical manifestation of porencephaly.
Adult acquired porencephaly is seldom reported in the literature, clinical manifestations depending on the location and size of the cyst. In the present reported case, increased susceptibility to low-dose opioids might be associated with the structural and functional reorganisation of the brain after head trauma with the occurrence of the porencephalic cyst of the brain.
Dan Sebastian Dîrzu, Cosmin Dicu and Noémi Dîrzu
Objective: Continuous quadratus lumborum (QL) analgesia is a new option for proximal femur surgery considered safe and effective. The purpose of this report was to show that we may not be aware of all the possible complications of this technique, and urinary retention may occur even when the block is performed unilaterally.
Case report: To an obese, intubated, mechanically ventilated, female patient, operated in prone position for removal of a femur tumour, we performed a trans-muscular quadratus lumborum block (TQL). We mounted a catheter and administered continuous infusion of local anaesthetic in the postoperative period. The patient experienced urinary retention. A urinary catheter was placed and it was maintained for the entire period of local anaesthetic infusion. When the catheter was removed, 72 hours after the surgery, the patient resumed normal bladder functions.
Conclusion: Urinary retention is a possible complication when continuous quadratus lumborum analgesia is used, even when performed unilaterally.
Rohit Kumar Varshney, Megha Garg, Kali Kapoor and Gurdeep Singh Jheetay
Background and Aim: Intra/post-operative shivering is frequently observed in parturients posted for elective cesarean delivery (C/D) under spinal anaesthesia. Several studies have advocated the anti-shivering effect of 5-HT3 antagonists, although none has revealed convincing results. The study aims to evaluate the prophylactic effect of a single intravenous dose of ramosetron (0.3 mg), compared with a placebo (N – normal saline), for the prevention of post-spinal shivering (PSS) during elective C/D.
Method: The study comprised 80 parturients of the American Society of Anaesthesiologists (ASA) physical status I/ II, posted for elective C/D under spinal anaesthesia who were randomly divided into 2 equal groups; Group N: 0.9% normal saline (4 ml) immediately before induction of spinal anaesthesia and Group R: ramosetron (0.3 mg) intravenously diluted to 4 ml volume. Shivering at any time on a (0-4) scale and total dose of tramadol required for its treatment was recorded. The study also includes the recording of haemodynamic parameters and the incidence of early onset nausea and vomiting.
Results: Statistically significant data was obtained while comparing incidence of shivering and maximum shivering at any time (P = 0.001). A lower incidence of early onset nausea and decreased total dose of tramadol was also observed in the ramosetron group.
Conclusion: Ramosetron (0.3 mg) is advocated to be an effective drug in preventing post-spinal shivering among parturients posted for elective C/D. Moreover, its role in preventing maternal nausea together with better haemodynamic parameters further supported the advantageous role of ramosetron in our group of patients.
Oksana V. Riazanova, Yuri S. Alexandrovich, Yana V. Guseva and Alexander M. Ioscovich
Background: Two methods of local anaesthetic administration into the epidural space in natural delivery pain management are compared in the article. Methods compared are programmed intermittent epidural bolus (PIEB) and continuous epidural infusion (CEI). Patient-controlled epidural analgesia was provided simultaneously in all cases.
Methods: 84 primipara with average age 30.7 (27.5-34) years, and gestational age 39.1 (38.5-40) weeks planned to natural delivery were examined. PIEB and patient controlled epidural analgesia was used in the first group. Patient controlled epidural analgesia and continuous epidural infusion (CEI) of local anaesthetic was used in the second group. Ropivacaine hydrochloride 0.08% without any adjuvants was utilized as local anaesthetic. Pain assessment was conducted using VAS while motor block was assessed using the Bromage scale.
Results: Labor progression dynamics and condition of newborns were equally independent to the method of analgesia. However, analgesic endpoint was better and more long-lasting while using PIEB with patient controlled epidural analgesia. Moreover, a lesser amount of local anaesthetic was consumed. In the group with programmed bolus, the total volume of local anaesthetic was 59.9 (45-66) ml in comparison with 69.5 (44-92) ml in the continuous infusion group (p = 0.033). The time to first bolus requested by the puerpera was significantly longer in the programmed bolus group – 89.2 (57-108) min compared to 43.2 (35-65) minutes in the continuous infusion group (p = 0.021).
Conclusion: Administration of low-concentrated ropivacaine solution 0.08% with no opioids using PIEB provides better and more prolonged analgesia with less local anaesthetic consumption and without any additional maternal and newborn side effects in comparison with continuous infusion.