1/816. paraplegia after thoracotomy--not caused by the epidural catheter.BACKGROUND: paraplegia and peripheral nerve injuries may arise after general anaesthesia from many causes but are easily ascribed to central block if the latter has been used. CASE REPORT: A 56-yr-old woman, with Bechterev disease but otherwise healthy, was operated with left-sided thoracotomy to remove a tumour in the left lower lobe. She had an epidural catheter inserted in the mid-thoracic area before general anaesthesia was started. bupivacaine 0.5% 5 ml was injected once and the infusion of bupivacaine 0.1% with 2 micrograms/ml fentanyl and 2 micrograms/ml adrenaline (5 ml/h) started at the end of surgery. The patient woke up with total paralysis in the lower limb and sensory analgesia at the level of T8, which remained unchanged at several observations. laminectomy, performed 17 h after the primary operation, showed a large piece of a haemostatic sponge (Surgicel) compressing the spinal cord, which was then decompressed but the motor and sensory deficit remained virtually unchanged both then and a year later. CONCLUSIONS: This case shows--once again--that although central blocks may cause serious neurological complications and paraplegia, other causes are possible and have to be considered. However, all patients with an epidural catheter must be monitored for early signs and symptoms of an intraspinal process and the appropriate treatment has to be instituted instantly.- - - - - - - - - - ranking = 1keywords = lower (Clic here for more details about this article) |
2/816. Large and giant middle to lower basilar trunk aneurysms treated by surgical and interventional neuroradiological methods.Treatment of large and giant aneurysms of the basilar artery remains difficult and controversial. Three large or giant aneurysms of the lower basilar artery were treated with a combination of surgical and interventional neuroradiological procedures. All patients underwent the balloon occlusion test with hypotensive challenge (blood pressure reduced to 70% of the control value). The third patient did not tolerate the test. In the first patient, both vertebral arteries were occluded through a craniotomy. In the second patient, both the aneurysm and the basilar artery were occluded by detached balloons. In the third patient, one vertebral artery was occluded by surgical clipping and the other by detached helical coils and fiber coils. In spite of anti-coagulation and anti-platelet therapy, postoperative thrombotic or embolic ischemia occurred in the second and third patients. Fibrinolytic therapy promptly corrected the ischemic symptoms, but the second patient developed hemorrhagic complications at the craniotomy area 2 hours later. At follow-up examination, the first patient had only 8th cranial nerve paresis, the second patient who had a hemorrhagic complication was bed-ridden, and the third patient had no deficit. Interventional occlusion requires a longer segment of the parent artery compared to surgical occlusion of the parent artery and might cause occlusion of the perforating arteries. However, selected use of various coils can occlude only a short segment of the parent artery. Thus, the postoperative management of thromboembolic ischemia after the occlusion of the parent artery is easier using the interventional technique.- - - - - - - - - - ranking = 2.5keywords = lower (Clic here for more details about this article) |
3/816. diagnosis and management of primary hyperoxaluria type 1 in infancy.We report a case of a 6-month-old infant who presented with failure to thrive due to end-stage renal disease as a result of primary hyperoxaluria type 1. The infant was managed with a combined daily hemodialysis and peritoneal dialysis prescription in order to manage the total body oxalate burden. Medical management included oral pyridoxine, aggressive hydration and nutritional supplementation via an enteral feeding tube. At one year of age the infant underwent a combined liver/kidney transplantation with intra- and daily post-operative hemodialysis to prevent oxalate deposition in the newly transplanted organs. The post-operative course was complicated by gross hematuria and increased hyperoxaluria, requiring an increase in hydration and thiazide diuretics. This infant received a combination of dialysis modalities which was designed to lower the potential oxalate burden prior to transplantation. This case illustrates the difficulty in medical management of an infant pre- and post-combined liver/kidney transplantation.- - - - - - - - - - ranking = 0.5keywords = lower (Clic here for more details about this article) |
4/816. Video-assisted crossover iliofemoral obturator bypass grafting: a minimally invasive approach to extra-anatomic lower limb revascularization.Graft infection continues to be one of the most feared complications in vascular surgery. It can lead to disruption of anastomoses with life-threatening bleeding, thrombosis of the bypass graft, and systemic septic manifestations. One method to ensure adequate limb perfusion after removal of an infected aortofemoral graft is extra-anatomical bypass grafting. We used a minimally invasive, video-assisted approach to implant a crossover iliofemoral obturator bypass graft in a patient with infection of the left limb of an aortofemoral bifurcated graft. This appears to be the first case report describing the use of this technique.- - - - - - - - - - ranking = 2keywords = lower (Clic here for more details about this article) |
5/816. Transient pseudo-hypoaldosteronism following resection of the ileum: normal level of lymphocytic aldosterone receptors outside the acute phase.Pseudo-hypoaldosteronism (PHA) is due to mineralocorticoid resistance and manifests as hyponatremia and hyperkalemia with increased plasma aldosterone levels. It may be familial or secondary to abnormal renal sodium handling. We report the case of a 54-year-old woman with multifocal cancer of the colon, who developed PHA after subtotal colectomy, ileal resection and jejunostomy. She was treated with 6 g of salt daily to prevent dehydration, which she stopped herself because of reduced fecal losses. One month later she was admitted with signs of acute adrenal failure, i.e. fatigue, severe nausea, blood pressure of 80/60 mmHg, extracellular dehydration, hyponatremia (118 mmol/l); hyperkalemia (7.6 mmol/l), increased blood urea nitrogen (BUN) (200 mg/dl) and creatininemia (2.5 mg/dl), and decreased plasma bicarbonates level (HCO3-: 16 mmol/l; N: 27-30). However, the plasma cortisol was high (66 microg/100 ml at 10:00 h; N: 8-15) and the ACTH was normal (13 pg/ml, N: 10-60); there was a marked increase in plasma renin activity (>37 ng/ml/h; N supine <3), active renin (869 pg/ml; N supine: 1.120), aldosterone (>2000 pg/ml; N supine <150) and plasma AVP (20 pmol/l; N: 0.5-2.5). The plasma ANH level was 38 pmol/l (N supine: 5-25). A urinary steroidogram resulted in highly elevated tetrahydrocortisol (THF: 13.3 mg/24h; N: 1.4 /-0.8) with no increase in tetrahydrocortisone (THE: 3.16 mg/24h; N: 2.7 /-2.0) excretion, and with low THE/THF (0.24; N: 1.87 /-0.36) and alpha THF/THF (0.35; N: 0.92 /-0.42) ratios. The number of mineralocorticoid receptors in mononuclear leukocytes was in the lower normal range for age, while the number of glucocorticoid receptors was reduced. Small-bowel resection in ileostomized patients causes excessive fecal sodium losses and results in chronic sodium depletion with contraction of the plasma volume and severe secondary hyperaldosteronism. Nevertheless, this hyperaldosteronism may be associated with hyponatremia and hyperkalemia suggesting PHA related to the major importance of the colon for the absorption of sodium. In conclusion, this case report emphasizes 1) the possibility of a syndrome of acquired PHA with severe hyperkalemia after resection of the ileum and colon responding to oral salt supplementation; 2) the major increase in AVP and the small increase in ANH; 3) the strong increase in urinary THF with low THE/THF and alpha THF/THF ratios; 4) the normal number of lymphocytic mineralocorticoid receptors outside the acute episode.- - - - - - - - - - ranking = 0.5keywords = lower (Clic here for more details about this article) |
6/816. Fatal late multiple emboli after endovascular treatment of abdominal aortic aneurysm. Case report.BACKGROUND: The short term experience of endovascular treatment of abdominal aortic aneurysms (AAA) seems promising but long term randomised data are lacking. Consequently, cases treated by endovascular procedures need to be closely followed for potential risks and benefits. CASE REPORT: A 70 year-old mildly hypertensive male without previous or present arteriosclerotic, pulmonary, or urological manifestations was subjected to endovascular treatment after his mass-screening diagnosed abdominal aortic aneurysm had expanded to above 5 cm in diameter, the aneurysm having been found by CT-scanning and arteriography to be endovascularly treatable. A Vanguard bifurcated aortic stent graft was implanted under epidural/spinal anaesthesia and covered by cephalosporine and heparin (8000 IE) protection. Apart from treatment of a groin haematoma and stenosis of the left superficial femoral artery, the postoperative period presented no problems. A few days before the monthly follow-up visit, the patient developed uraemia, gangrene of one foot and dyspnoea. blood glucose and LDH was elevated. Deterioration led to death a month and a half after stent implantation. autopsy showed extraordinary large, extensive soft, brown vegetations in the lower part of the thoracic aorta above the properly infrarenally-placed stent. Microscopic examination revealed multiple microemboli in the liver, spleen, pancreas, intestines, testes, and especially the kidneys. DISCUSSION: Early death from microemboli after aortic stent implantation has been reported. However, the present case developed fatal multiple microemboli so late that they could not have originated from the excluded mural thrombus. The sudden death of an otherwise healthy man of extensive microemboli is difficult to explain. The stent application may have altered the proximal flow and wall movements disposing to microemboli in the case of vegetations.- - - - - - - - - - ranking = 0.5keywords = lower (Clic here for more details about this article) |
7/816. iliac artery pseudoaneurysm following renal transplantation presenting as lumbosacral plexopathy.A renal transplant patient developed chronic and progressive back and lower extremity pain followed by foot weakness. The correct diagnosis of lumbosacral plexopathy was made after electromyography and nerve conduction studies and the etiology of radiculopathy due to nerve root compression was excluded. This prompted further investigations that led to the discovery of a large internal iliac artery pseudoaneurysm. We emphasize the use of electrodiagnostic studies to investigate patients with back and limb pain for correctly localizing responsible pathology. In this case a potentially lethal situation was correctly identified in a transplant patient.- - - - - - - - - - ranking = 0.5keywords = lower (Clic here for more details about this article) |
8/816. Ogilvie's syndrome after lower extremity arthroplasty.OBJECTIVE: To alert surgeons who perform arthroplasty to the possibility of acute colonic pseudo-obstruction (Ogilvie's syndrome) after elective orthopedic procedures. To identify possible risk factors and emphasize the need for prompt recognition, careful monitoring and appropriate management so as to reduce morbidity and mortality. DESIGN: A case series. SETTING: A university-affiliated hospital that is a major referral centre for orthopedic surgery. patients: Four patients who had Ogilvie's syndrome after lower extremity arthroplasty. Of this group, 2 had primary hip arthroplasty, 1 had primary knee arthroplasty and 1 had revision hip arthroplasty. MAIN OUTCOME MEASURES: morbidity and mortality. RESULTS: In all 4 patients Ogilvie's syndrome was recognized late and required surgical intervention. Two patients died as a result of postoperative complications. CONCLUSIONS: Our case series identified increasing age, immobility and patient-controlled narcotic analgesia as potential risk factors for Ogilvie's syndrome in the postoperative orthopedic patient. Prompt recognition and early consultation with frequent clinical and radiographic monitoring are necessary to avoid colonic perforation and its significant associated death rate.- - - - - - - - - - ranking = 2.5keywords = lower (Clic here for more details about this article) |
9/816. Postoperative acute pulmonary thromboembolism in patients with acute necrotizing pancreatitis with special reference to apheresis therapy.Eight patients with pancreatic abscesses secondary to acute necrotizing pancreatitis underwent drainage of their abscesses under laparotomy. Two of them died of acute pulmonary thromboembolism (PTE) within 1 week. autopsy revealed a large thrombus at the main trunk of the pulmonary artery and in the left common iliac vein. Femoral catheter insertion/indwelling, immobilization, surgery, increased trypsin/kinin/kallikrein, increased endotoxin, and decreased antithrombin-III (AT-III) were present following drainage of the pancreatic abscesses. With respect to the bedside diagnosis of acute PTE, alveolar-arterial oxygen gradients obtained by blood gas analysis and mean pulmonary artery pressure estimated by pulsed Doppler echocardiography are very useful. In terms of the treatment, attention should be paid to the following to prevent deep venous thrombosis: prophylactic administration of low molecular weight heparin and administration of AT-III (AT-III > or = 80%), use of the subclavian vein whenever possible as blood access for apheresis therapy, as short a compression time as possible after removing the blood access catheter (< or =6 h), and application of intermittent pneumatic compression devices or elastic compression stockings on the lower extremities.- - - - - - - - - - ranking = 0.5keywords = lower (Clic here for more details about this article) |
10/816. Excision of spinal tumor in a patient with severe pulmonary dysfunction using combined spinal and epidural anesthesia with two epidural catheters.BACKGROUND AND OBJECTIVES: Combined spinal and epidural anesthesia (CSEA) has become common practice. We performed CSEA using two epidural catheters in a 69-year-old female with severe pulmonary dysfunction caused by a diaphragmatic hernia, who underwent surgical excision of a lumbar spinal tumor. methods: Combined spinal and epidural anesthesia was performed using two epidural catheters to minimize postoperative pulmonary complications. One epidural catheter was inserted above the surgical region, at the T11-12 interspace, and another one below the surgical region, via the sacral hiatus. Spinal anesthesia was produced using the L5-S1 interspace and 3 mL 0.5% bupivacaine. oxygen, 3 L/min, was administered through a face mask during surgery. RESULTS: Fifteen minutes after spinal anesthesia, analgesic level was confirmed below T7 using the pinprick method. The patient complained of pain in the surgical region 10 minutes after the dura mater was opened. We injected 5 mL 2% mepivacaine through the upper epidural catheter to relieve the pain. We also injected 10 mL 2% mepivacaine through the lower catheter when she felt pain in the right leg. The perioperative course was uneventful. oxygen saturation was maintained above 95%. CONCLUSIONS: Combined spinal and epidural anesthesia using two epidural catheters was used successfully to excise a spinal tumor in a patient with severe pulmonary dysfunction.- - - - - - - - - - ranking = 0.5keywords = lower (Clic here for more details about this article) |
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