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.
Ario Santini, Leonard Azamfirei and Cosmin Moldovan
Zoltán Ruszkai, Erika Kiss and Zsolt Molnár
Lung protective mechanical ventilation (LPV) even in patients with healthy lungs is associated with a lower incidence of postoperative pulmonary complications (PPC). The pathophysiology of ventilator-induced lung injury and the risk factors of PPCs have been widely identified, and a perioperative lung protective concept has been elaborated. Despite the well-known advantages, results of recent studies indicated that intraoperative LPV is still not widely implemented in current anaesthesia practice.
No nationwide surveys regarding perioperative pulmonary protective management have been carried out previously in Hungary. This study aimed to evaluate the routine anaesthetic care and adherence to the LPV concept of Hungarian anaesthesiologists during major abdominal surgery.
A questionnaire of 36 questions was prepared, and anaesthesiologists were invited by an e-mail and a newsletter to participate in an online survey between January 1st to March 31st, 2018.
A total of one hundred and eleven anaesthesiologists participated in the survey; 61 (54.9%), applied low tidal volumes, 30 (27%) applied the entire LPV concept, and only 6 (5.4%) regularly applied alveolar recruitment manoeuvres (ARM). Application of low plateau and driving pressures were 40.5%. Authoritatively written protocols were not available resulting in markedly different perioperative pulmonary management. According to respondents, the most critical risk factors of PPCs are chronic obstructive pulmonary diseases (103; 92.8%); in contrast malnutrition, anaemia or prolonged use of nasogastric tube were considered negligible risk factors. Positive end-expiratory pressure (PEEP) and regular ARM are usually ignored. Based on the survey, more attention should be given to the use of LPV.
Bhavna P Singh, Gurucharan S Shetty, Padmakumar Arayamparambil Vijayan, Ullas Gopalakrishna, Garud Chandan, Ario Santini and Vivek Padegal
H1N1 is seen in tropical countries like India, occurring irrespective of the season. Complications of the disease are frequently encountered and there is little in the way or guidelines as to the how these should be managed. The treatment of one such complication, a recurrent pneumiomediastinum is the subject of the current paper. The management followed guidance for the treatment of a similar condition known as primary spontaneous pneumomediastinum, an uncommon condition resulting from alveolar rupture-otherwise known as the Macklin phenomenon.