1/33. air embolism during tunneled central catheter placement performed without general anesthesia in children: a potentially serious complication.central venous catheters have had an increasingly important role in a variety of patient care situations, including long-term antibiotic therapy, chemotherapy, and nutritional support. The recent past has seen a gradual transition from placement of vascular access catheters by surgeons to placement by interventional radiologists. The interventional radiology service places a majority of the vascular access devices at our children's hospital, including peripherally inserted central catheters, tunneled central venous catheters, temporary and permanent hemodialysis catheters, and subcutaneous ports. Most procedures performed by our interventional radiology service in children can be successfully completed with use of intravenous (i.v.) sedation, and a few require general anesthesia (GA). Key advantages of GA over i.v. sedation include the ability to have positive pressure ventilation (PPV) or controlled apnea during the procedure. We report our experience of venous air embolism in three small children during placement of tunneled central venous catheters when GA was not used.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
2/33. Fatal pulmonary haemorrhage during anaesthesia for bronchial artery embolization in cystic fibrosis.Three children with cystic fibrosis (CF) had significant pulmonary haemorrhage during anaesthetic induction prior to bronchial artery embolization (BAE). Haemorrhage was associated with rapid clinical deterioration and subsequent early death. We believe that the stresses associated with intermittent positive pressure ventilation (IPPV) were the most likely precipitant to rebleeding and that the inability to clear blood through coughing was also an important factor leading to deterioration. Intermittent positive pressure ventilation should be avoided when possible in children with CF with recent significant pulmonary haemorrhage.- - - - - - - - - - ranking = 2keywords = pressure (Clic here for more details about this article) |
3/33. Pneumoparotid due to spirometry.Pneumoparotid has been described in patients who generate increased intraoral pressures when playing wind instruments, while coughing, and when undergoing dental work. Some patients have intentionally created pneumoparotid to avoid duties at school or in the military, or to gain attention. We describe a patient who developed pneumoparotid during pulmonary function testing. The diagnosis of pneumoparotid depends on a suggestive clinical situation and glandular swelling with or without crepitus. observation of aerated saliva per Stensen's duct or air in the parotid duct and/or gland by any imaging study is diagnostic if infection with a gas-forming organism can be reasonably excluded. No specific treatment is required, other than the avoidance of predisposing activities.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
4/33. A case of pulmonary arteritis with stenosis of the main pulmonary arteries with positive myeloperoxidase-antineutrophil cytoplasmic autoantibodies.A 53-year-old woman was referred to our hospital with the main symptoms of productive cough, fever and exertional dyspnoea. Chest X-ray revealed enlargement of the left hilar shadow and cavitary infiltration in the right upper lobe. 99mTechnetium-macroaggregated albumin (99mTc-MAA) perfusion scintigram showed complete hypoperfusion through the entire right lung. A pulmonary angiogram revealed stenotic lesions in the right and left main pulmonary arteries. Right cardiac catheterization showed an elevated right ventricular systolic pressure. There was no evidence of systemic arterial lesions nor vasculitis. The patient was positive for myeloperoxidase (MPO)-antineutrophil cytoplasmic autoantibodies (ANCA) (168 EU). The mycobacterium avium complex sputum culture was positive. The pulmonary stenotic lesions were surgically resected. The resected pulmonary arterial lesions were pathologically diagnosed as non-specific vasculitis. The cavitary lesion disappeared 6 months after the surgery. Two years after the surgery, although the MPO-ANCA level had decreased to 12 EU, stenosis of the pulmonary arteries reappeared. It is suggested that the patient became positive for MPO-ANCA in association with the mycobacterium avium complex infection, and that the presence of MPO-ANCA may not be related to the development of pulmonary stenosis of the main pulmonary arteries.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
5/33. Electrical stimulation of abdominal muscles for control of blood pressure and augmentation of cough in a C3/4 level tetraplegic.OBJECTIVES: Evaluation of a FES (Functional Electrical Stimulation) device for the relief of postural hypertension and augmentation of cough in a C3 ventilator-dependent tetraplegic. STUDY DESIGN: A single case study. SETTING: A supra regional spinal unit in the UK. METHOD: A dual channel stimulator was designed that allowed selection and initiation of two predetermined stimulation intensities using a chin controlled joystick. Two sets of 70 mm diameter electrodes were placed either side of the abdomen. Approximately 80 mA, 300 micros, 40 Hz was required for assisted cough while about 40 mA was required for maintenance of blood pressure. After eating, the lower level stimulus is self-administered every 3 to 5 min gradually increasing the time between groups of burst to once every hour after 90 min. RESULTS: Following eating, a blood pressure of 60/45 mmHg was recorded. After five 1 s bursts of stimulation in quick repetition, this was increased to 133/92 mmHg. After 2 min blood pressure had fallen to 124/86 mmHg and to 93/66 after a further 4 min. The electrical stimulation was then repeated, returning the blood pressure to the previous higher level. Measurement of peak expiratory flow showed an increase from 275 l/min for an unassisted cough to 425 l/min when using the device. CONCLUSION: The device is used every day. The user is now independent in coughing function and no longer requires suction or manual assistance. maintenance of blood pressure has significantly improved his quality of life.- - - - - - - - - - ranking = 9keywords = pressure (Clic here for more details about this article) |
6/33. Severe cough: a cause of late bleb leak.PURPOSE: To highlight coughing as a potential cause for late postoperative trabeculectomy bleb leaks. methods: A retrospective study of 2 patients in whom late bleb leaks developed after a bout of severe coughing. Perioperative 5-fluorouracil was used at the time of the initial filtration procedure for one of the patients, while the second patient had had an ordinary trabeculectomy. Both patients required surgical repair of their bleb leak to manage the resultant hypotony. RESULTS: Postoperatively, both patients had good intraocular pressure control and maintained their visual fields without topical medications. Both patients demonstrated bleb avascularity after leak repair. CONCLUSIONS: trabeculectomy bleb leaks are well recognized. Bleb leaks in the late postoperative period are more common after the perioperative use of antimetabolites, and spontaneous leaks after minimal trauma have been described. The authors describe 2 cases of late spontaneous bleb leaks after severe coughing, both of which responded well to surgical correction. The importance of inquiring about a history of coughing with late bleb leaks in the absence of other causative factors is stressed.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
7/33. Infectious disease capsules: a pox on your house.A 31-year-old, previously healthy white man presented to the emergency department with complaints of malaise, fevers, shortness of breath, a non-productive cough, and a "rash." His physical exam revealed a temperature of 100.2F, a pulse of 129 bpm, respiratory rate of 14 BPM, and blood pressure of 140/74 mm Hg. He was alert, oriented, and in no distress. His oropharynx was dry, his neck was supple, and cervical lymphadenopathy was absent. He had tachycardia, bilateral wheezes, and rhonchi with prolonged expirations. There was a diffuse vesicular eruption enveloping his entire body with involvement sparing his palms and soles (Figures 1 and 2). Laboratory values showed a hemoglobin of 16.0 g/dL and a white blood cell count of 7100 cells/pL, with 39%neutrophils, 23% bands, and 35% lymphocytes. His platelet count was mildly decreased to 86,000 x 103/pL. Chest radiograph revealed bilateral diffuse interstitial infiltrates. A diagnosis of acute varicella-zoster virus pneumonia (varicella pneumonia) was made, and the patient was started on IV acyclovir (10 mg/kg every 8 hours). Upon further questioning, the patient stated that his daughter had been diagnosed with "chickenpox" 7 days ago. The patient had numerous exposures to chickenpox in the past but had never developed clinical expressions of varicella. He was not at risk for hiv infection, not having multiple sexual partners, IV drug abuse, or blood transfusions. During the 1 day of in-hospitalization, his fever abated and the pulmonary signs diminished.Following discharge, IV acyclovir was replaced by valacyclovir to complete a 7-day course of therapy.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
8/33. Cases from the Osler Medical Service at Johns Hopkins University. diagnosis: P. carinii pneumonia and primary pulmonary sporotrichosis.PRESENTING FEATURES: A 53-year-old man who had human immunodeficiency virus (hiv) presented to the Johns Hopkins Hospital with a 3-month history of increasing dysphagia, cough, dyspnea, chest pain, and an episode of syncope. His past medical history was notable for oral and presumptive esophageal candidiasis that was treated with fluconazole 6 months prior to presentation. Three months prior to presentation, he discontinued his medications, and his symptoms of dysphagia recurred. During that time he developed intermittent fevers and chills, progressively worsening dyspnea on exertion, and a cough productive of white sputum. He also reported a 40-lb weight loss over the past 3 months. On the day prior to presentation, he had chest pain and shortness of breath followed by weakness, dizziness, and a brief syncopal episode. He denied orthopnea, paroxysmal nocturnal dyspnea, lower extremity edema, jaundice, hemoptysis, hematemesis, melena, hematochezia, or diarrhea. There was no history of alcohol use, and he stopped smoking tobacco approximately 1 month previously. He smoked cocaine but denied injection drug use. The patient had never been on antiretroviral therapy and had never had his CD4 count or viral load measured. On physical examination, the patient was a thin, cachectic man who appeared older than his stated age. His vital signs were notable for blood pressure of 102/69 mm Hg, resting tachycardia of 102 beats per minute, resting oxygen saturation of 92% on room air, normal resting respiratory rate, and a temperature of 38.1 degrees C. His oropharynx was clear, with no signs of thrush or mucosal ulcers. His pulmonary examination was notable for diminished breath sounds in the lower lung fields bilaterally. Cardiac, abdominal, and neurologic examinations were normal. His skin was intact, with no visible petechiae, rashes, nodules, or ulcers. Laboratory studies showed a total white blood cell count of 3.2 x 10(3)/microL, with a total lymphocyte count of 330/microL, hematocrit of 30.2%, a serum sodium level of 129 mEq/L, and a serum lactate dehydrogenase level of 219 IU/L. The patient had an absolute CD4 count of 8 cells/mm3 and a hiv viral load of 86,457 copies/mL. His arterial blood gas on room air had a pH of 7.51, a PCO2 of 33 mm Hg, and a PO2 of 55 mm Hg. Electrocardiogram and serial serum cardiac enzymes were normal. A chest radiograph showed bilateral upper lobe patchy infiltrates with left upper lobe consolidation. Computed tomographic (CT) scan of the chest with contrast showed bilateral ground glass infiltrates with focal consolidation (Figure 1) and no evidence of pulmonary embolism. Induced sputum was negative for pneumocystis carinii, fungi, or acid-fast bacilli. A bronchoalveolar lavage was performed. What is the diagnosis?- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
9/33. Interpretation of cardiac pathophysiology from pressure waveform analysis: coronary hemodynamics. Part II: Patterns of coronary flow velocity.These specialized tracings illustrate several important patterns of coronary blood flow velocity that may occur in patients during diagnostic cardiac catheterization. Recent advances in catheter methodologies permit easy measurement of coronary blood flow during routine coronary angiography. At the current time, measurement of coronary blood flow velocity remains a research technique but is of continuing interest in clinical syndromes of atypical angina, myocardial hypertrophy and infarction, early transplant rejection, or premature (subangiographic) atherosclerosis in some patients. A later hemodynamic rounds will examine the effects of coronary blood flow velocity and various hyperemic stimuli to assess coronary vasodilatory reserve.- - - - - - - - - - ranking = 4keywords = pressure (Clic here for more details about this article) |
10/33. Latent fatality due to hydatid cyst rupture after a severe cough episode.Hydatid disease is a parasitic disease caused by echinococcus granulosus characterised by cyst formation in various organs. The infestation mostly involves the liver. Hydatid cysts of the liver can rupture either spontaneously or due to trauma. incidence of rupture is about 3-17% of all cases with hydatid disease. Unless treated surgically, rupture can result in death. Here, we present a case of hydatid cyst ruptured after a severe cough episode and disseminated first to the subcapsular area, then to the peritoneal space. Probably due to a decrease in parenchymal pressure in the liver after decompressive effect of rupture, the patient felt an improvement in abdominal pain, refused operation, and left the hospital on his own responsibility. This unfortunate relief resulted in a delay of 55 hours in management. The leakage of liquid materials into peritoneal space resulted in a severe inflammatory reaction and eventually death of the patient. The patient died of a late peritonitis rather than anaphylaxis, which is the most common reason for death in such patients. As a conclusion, physicians should be aware of a temporary relief in abdominal pain after cyst rupture that may cause a delay in management and in turn loss of patient due to peritonitis.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
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