Curēus
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High-frequency oscillatory ventilation (HFOV) may assist in the prevention of volutrauma for high-risk patients with acute respiratory distress syndrome (ARDS) during venovenous extracorporeal membrane oxygenation (VV ECMO). In combined VV ECMO and HFOV, we noted that increased intrathoracic pressure contributed to shunt formation in the dual-lumen Avalon® cannula (Maquet, Rastatt, Germany). A 51-year-old female with ARDS secondary to aspiration pneumonia was placed on VV ECMO using a single Avalon cannula. ⋯ We noted that a flash of bright red, oxygenated blood was flowing retrograde in the Avalon cannula at the same rate as the beat of the oscillator, while the patient's ECMO flow rate, arterial blood gas, and blood pressure all remained stable. The ECMO flow was increased above 5.5 L/min and the resolution of the retrograde shunt through the Avalon cannula was immediately observed. Concurrent use of HFOV with VV ECMO using an Avalon cannula may result in a shunt that becomes visible with arterial O2 saturations nearing 100%. Due to pressure differences between the venous and arterial lumens of the Avalon cannula, increasing the ECMO flow rate appeared to decrease this shunting effect caused by elevated intrathoracic pressure.
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Cefepime is a fourth-generation cephalosporin widely used to treat gram-positive and gram-negative infections. Its half-life is approximately two hours in patients with normal renal function and may increase to 13.5 hours in patients with acutely or chronically impaired renal function. ⋯ While the pathophysiology is unclear, treatment involves early discontinuation of this antibiotic to decrease morbidity and mortality. We report five cases of cefepime-induced encephalopathy occurring within one year at a single institution.
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Case Reports
Lateral Femoral Cutaneous Nerve Decompression Guided by Preoperative Ultrasound Mapping.
Injury to the lateral femoral cutaneous nerve (LFCN) from compression or entrapment may result in meralgia paresthetica, a painful mononeuropathy of the anterolateral thigh. Surgical decompression of the LFCN may provide relief when conservative management fails. However, the considerable anatomic variability of this nerve may complicate surgical localization and thus prolong operative time. ⋯ This simple, noninvasive imaging technique was seen to be effective at providing precise localization of the entrapped and, in this case, bilateral anatomically variant nerves. Preoperative high-resolution ultrasound mapping of the LCFN can be used to facilitate precise operative localization in the treatment of bilateral meralgia paresthetica. This is especially useful in the setting of suspected unusual nerve anatomy.
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Total knee arthroplasty (TKA) is the most common joint replacement surgery performed in the United States. Given the aging and increasingly comorbid patient populations undergoing these procedures, complication rates and the need for subsequent hospital readmission are only expected to rise. It is, therefore, crucial to investigate the risk factors leading to readmission in order to improve patient outcomes. The purpose of this study is to identify significant risk factors for readmission following revision TKA procedures. ⋯ This study was successful in identifying variables associated with readmission following revision TKA, as well as presenting information regarding the diagnoses associated with readmission. Our data also showed that if a patient was readmitted after revision TKA, it was likely that they would be admitted again. Due to the increasing prevalence and cost of these procedures, further studies are needed to better understand the risk factors and comorbidities leading to readmission in order to improve the perioperative care of these patients.
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Management of cerebrospinal fluid (CSF) leak during minimally invasive lumbar tubular microdiscectomy poses challenges unique to the surgical approach. Primary repair can be limited via tubular retractor systems, and onlay graft and dural sealant are often the treatment of choice intraoperatively. Postoperative persistent CSF leak may lead to intracranial hypotension (IH) and positional headaches. Early epidural blood patch (EBP) efficacy in the treatment of spinal CSF leaks of both spontaneous and iatrogenic origin is well-established in numerous studies. However, there is no consensus on treatment of persistent IH symptoms for patients undergoing lumbar tubular microdiscectomy. ⋯ Both patients received an early EBP with an immediate and complete resolution of positional headaches sparing them reoperation and/or lumbar drainage. EBP should be considered as a first-line treatment to treat postoperative IH symptoms without pseudomeningocele after iatrogenic CSF leak during tubular microdiscectomy.