Independent lung ventilation for treatment of post-traumatic ARDS

BACKGROUND

Independent lung ventilation (ILV) has been recommended for unilateral pulmonary pathology. We describe a case of a multiple trauma patient treated with ILV for unilateral lung injury.

CASE REPORT

Following a road accident, an 18 year-old male patient was referred to the university hospital with multiple organ failure, a ruptured liver and spleen, a fractured spine at the Th1-2 level, and left lung contusion. Splenectomy and liver repair had been performed in a regional hospital. On admission, a left sided pneumothorax and haemothorax were diagnosed and an emergency thoracotomy was performed, with partial resection of the left lower lobe. Because of the failure of recruitment of the left upper lobe, the patient was intubated with a double lumen tube and ILV was started using a single ventilator and a prototype flow separator, allowing separation of volume and PEEP settings. The left lung was ventilated with larger volumes and a higher PEEP than the right side, resulting in rapid improvement of gas exchange, reduction of air leak, and a return to conventional ventilation within two days. The patient underwent spinal stabilisation, and was extubated a few days later and transferred to a rehabilitation unit.

CONCLUSIONS

ILV with a larger tidal volume and high PEEP may be indicated in unilateral lung injury with a significant air leak from the injured tissue.

Coronary air embolism during removal of a central venous catheter

BACKGROUND

Acute air embolism has been described during central venous cannulation, but it may also occur during catheter removal in a spontaneously breathing patient. We describe an episode of acute coronary ischaemia that occurred during CV catheter removal.

CASE REPORT

A 23-year-old male, multiple trauma patient was treated over 27 days in an ITU. He required a tracheostomy, two weeks of mechanical ventilation, and several surgical interventions. On the 27th day, he was scheduled to be transferred to a low-dependency area and his CVC was removed from the left subclavian vein. After five minutes, the pressure pad was released from the site of cannulation; the patient started coughing and became dyspnoeic. He developed tachyarrhythmia with ST depression in the 2nd, 3rd and aVF leads, followed by marked ST elevation, and subsequently, ventricular fibrillation. The patient was placed in the Trendelenburg position and CPR was started. Normal sinus rhythm returned after three defibrillations. Echocardiography revealed the presence of a large amount of air bubbles within the left ventricle, which disappeared spontaneously within one minute. The patient quickly regained consciousness and his condition returned to normal within 12 h, with transient elevation of heart enzymes. Five days later, he was decannulated and transferred to the orthopaedic ward in a satisfactory condition.

DISCUSSION

Air embolism during CV catheter removal is a rare event, but it may occur when a persistent tunnel remains after prolonged cannulation, associated with negative intrathoracic pressure created by a spontaneously breathing or coughing patient. In the case described, acute myocardial ischaemia occurred in the region supplied by the right coronary artery, which is located higher than the left one and is therefore more exposed to air bubbles. We could not demonstrate, however, the presence of a persistent foramen ovale, however some connection had to exist between the right and left sides of the heart in our patient.

CONCLUSION

Special caution should be exercised during CV catheter removal, and the procedure should be always done with the patient placed in the Trendelenburg position.

[Tricuspidal valve rupture after blunt chest trauma]

BACKGROUND

Blunt chest trauma is frequently associated with cardiac contusion and structural damage, most cases only being recognized after death. We report a case of multiple organ trauma, where cardiac failure, caused by tricuspid valve rupture, was markedly delayed.

CASE REPORT

A 21 yr old man was admitted to hospital after a car accident. He was suffering from cerebral contusion and oedema, pulmonary contusion, and a left pneumothorax. He also had multiple fractures of the facial bones, orbit, L4 vertebra and left tibia. He was tracheotomised, and a subdural sensor was inserted for continuous monitoring of intracranial pressure. He was sedated and ventilated for two weeks. On the 12th day, his jaw was reconstructed, and immediately after surgery, mild signs of cardiac failure were observed, which were attributed to cardiac contusion. Two weeks after admission, the patient was weaned from the ventilator, and three days later, his facial bones were reconstructed. Four days later, the signs of cardiac failure reappeared. Transoesophageal echocardiography revealed rupture of a head of papillary muscle, with 4th degree tricuspid insufficiency and enlargement of the right ventricle. The ruptured muscle was reconstructed under extracorporeal circulation, and the patient made a satisfactory recovery.

DISCUSSION

Acute tricuspid valve insufficiency, albeit rare, may occur in patients with blunt chest trauma. Sedation and lack of physical activity may delay the definite diagnosis, especially when only transthoracic echocardiography is used. Cardiac arrhythmias, diastolic murmur, or signs of congestive cardiac failure in a chest trauma patient may all suggest some structural damage; therefore, transoesophageal echocardiography should be performed as early as possible in such situations.

[Pneumocephalus and pneumorrhachis after chest wall injury]

Pneumocephalus and pneumorrhachis are rare findings, and may result from a variety of causes, including severe asthma or trauma. We describe a case, where intracranial and intraspinal air was found after trauma to the chest wall.

CASE REPORT

A 24-yr-old patient suffered multiple trauma in a traffic accident, including a closed head injury and bursting fractures of theTh 7, 8 and 9 vertebral bodies with laceration of the spinal cord. Reposition of the spinal column was complicated by wound infection and septic shock. Intraoperatively, accidental extubation led to migration of gastric contents and was complicated by possible rupture of the oesophagus. Postoperative CT scan revealed the presence of air within the mediastinum, cranium and the entire spinal canal. The osteosynthetic material was removed, and the air quickly reabsorbed. The paraplegic patient was discharged from ITU in a satisfactory condition.

DISCUSSION

The most probable cause of the complication was traumatic rupture of the oesophagus and penetration of air via lacerated dura mater, to the spinal canal and the cranium. Conservative treatment was successful and led to complete (beside paraplegia) recovery.

[Effects of cervical plexus block on lung ventilation]

BACKGROUND

Carotid endarterectomy is a preventative operation to reduce the incidence of embolic stroke. The prime concern during surgery is the protection of the brain during carotid artery cross-clamping. Since blood flow to the brain is provided via the non-affected carotid artery and collateral circulation, it is essential to maintain consciousness in the patient during surgery, in order to assess the effects of cross-clamping. Regional anaesthesia has therefore been regarded as the method of choice for this kind of surgery. Cervical plexus analgesia can be achieved at two levels: superficial--when skin branches of the plexus are blocked, and deep--when short and long nerves are blocked. Successful block of the cervical plexus depends of effective analgesia achieved at both levels. This can be achieved by a single injection as described by Winnie, or multiple injection at C2, C3 and C4 as described by Moore. Among possible complications, the most common is transient phrenic nerve block with diaphragm dysfunction.

METHODS

We have compared the effects of cervical plexus block performed according to Winnie (group W), or Moore (group M) on spirometry, arterial oxygen saturation and carbon dioxide tension, in seventy-five patients scheduled for endarterectomy.

RESULTS

Group W consisted of 44 patients, and group M--of 31 patients. VC, FVC, FEV1 and PIF decreased in all patients. There were no statistically significant differences between the groups. Transient paralysis of the diaphragm, confirmed by chest x-ray, occurred in 8 (19.5%) patients of group W, and in 4 (14.3%) patients of group M. Gas exchange remained unchanged.

CONCLUSIONS

We proved that cervical plexus block is associated with moderate depression of respiratory function without impairment of gas exchange. The block may be complicated by transient unilateral diaphragm paralysis.

[Comparison of two methods of cervical plexus block for carotid endarterectomy]

BACKGROUND

Cerebral thromboembolism is one of the main risks of carotid artery occlusive disease. Carotid endarterectomy is a preventive operation to reduce the incidence of embolic stroke. Of prime concern during this surgery is protection of the brain during carotid cross-clamping. Since blood flow to the brain is provided via the non-affected carotid artery and collateral circulation, it is essential to maintain the consciousness of the patient during surgery in order to assess the effects of cross-clamping. Changes in speech or motor function indicate inadequate perfusion and the need for immediate bypass. Regional anaesthesia has therefore been regarded as the method of choice in this kind of surgery.

METHODS

Seventy-five ASA I-III patients, scheduled for carotid endarterectomy, were randomly allocated to two groups to receive a combined cervical plexus block with two different techniques: according to either Winnie or to Moore. The quality of anaesthesia was compared using the Verbal Numeric Rating Score (VNRS) and the Visual Analogue Score (VAS).

RESULTS

Both methods were safe and provided fair analgesia, with similar patient satisfaction and minimal cardiovascular side effects. Serious cerebral ischaemia requiring temporary bypass occurred in three cases. Additional local infiltration was necessary in both groups.

CONCLUSION

The cervical plexus block, regardless of the technique used, provides high satisfaction and safety during cervical endarterectomy.

Use of drotrecorgin alfa--recombinant activated human protein C in treatment of septic shock in the course of therapy for nephrolithiasis

BACKGROUND

Septic shock is the most dangerous complication of nephrolithiasis management utilizing percutaneous methods.

CASE REPORT

The patient, D.M., aged 60 was subjected to scheduled percutaneous nephrolithotomy due to coral calculosis of the pyelocalyceal system. As pyuria was noted intraoperatively, nephrostomy was left after the procedure. Over ten hours after the surgery the patient developed the symptoms of severe septic shock with progressive respiratory distress, renal failure, intravascular coagulation syndrome and impaired consciousness. Nephrectomy was performed, antibiotic treatment and high doses of norepinephrine instituted. Hemodynamic stabilization was obtained, without, however, marked improvement of the patient's condition. Because of persistent coagulation disorders and multiorgan dysfunction, recombinant activated protein C preparation--drotrecorgin alfa (Xigris Eli Lilly) was added to the therapeutic regimen. From the second day of infusion, systematic improvement of the coagulation system parameters was observed, making it possible to reduce the doses of catecholamines, oxygen concentration in the gas mixture used for ventilation, as well as stabilization of the function of the preserved kidney. The patient was weaned off the respirator on the 8th day of treatment and on the 13th day referred to the Urology Department, from which she was soon discharged home.

CONCLUSIONS

1. Surgical resection of the infection source and cause of the septic shock is the prerequisite for successful pharmacological treatment. 2. Administration of rh-APC to a patient meeting the PROWESS criteria may be an effective and safe method of treatment in the complex management of septic shock.

[The influence of premedication with diclofenac or pethidine on pain and postop treatment in lumbar discopathy]

206 patients scheduled for spinal surgery (lumbar discopathy) were randomly premedicated with diclofenac, pethidine, diazepam or hydroxizine. The frequency of persisted postoperative pain was evaluated from the 3-ed. postoperative day to the end of hospitalisation--as the need for additional concomitant treatment with dexamethasone and intravenous analgesics. The frequency of persisted pain was significantly decreased in patients premedicated with diclofenac (together with diazepam) before spinal surgery (limited to fenestration) in comparison to patients premedicated with pethidine. The pre-emptive analgesic effect of diclofenac was even more evident in patients treated with non-steroidal anti-inflammatory drugs (NSAID) before surgery, but was not observed in patients after more traumatic surgery (laminectomy) premedicated with diazepam. The results are supporting the important role of NSAID given before surgery to decrease the frequency of persisted pain after spinal surgery (limited to fenestration), in patients treated with NSAID.