A & A case reports
-
Case Reports
Difficult Ventilation After Successful Intubation in the Emergency Setting Due to a Ball Valve Clot.
The inability to ventilate a patient after successful intubation is a rare but emergent situation and may be caused by obstruction of the endotracheal tube, bilateral tension pneumothorax, esophageal intubation, severe bronchospasm, or mainstem bronchus intubation. We describe an increase in mean airway pressure, inability to ventilate, and loss of cardiac output secondary to a blood clot acting as a ball valve at the end of an endotracheal tube.
-
Fixed and dilated pupils are disturbing when encountered during a physical examination in the pediatric intensive care unit, particularly when sedation or neuromuscular blockade confounds the neurologic examination. Rocuronium, a nondepolarizing neuromuscular drug, does not cross the blood-brain barrier and is not considered a causative agent for fixed mydriasis. We report a case of bilateral fixed and dilated pupils in a 1-week-old low-birth-weight neonate, which we contend was secondary to centrally mediated neuromuscular blockade.
-
Multicenter Study
Prophylactic Antibiotic Management of Surgical Patients Noted as "Allergic" to Penicillin at Two Academic Hospitals.
We studied prophylactic antibiotics administered at 2 academic medical centers during a 6-year period where a cephalosporin was indicated but an "allergy" to penicillin was noted. Another drug (typically vancomycin or clindamycin) was substituted approximately 80% of the time; this occurred frequently even when symptoms unrelated to acute hypersensitivity were listed. In >50% of cases, the reaction was either omitted or vague (e.g., simply "rash"). Given the estimated 1% cross-reactivity between penicillins and cephalosporins with similar R1 side chains, many of these patients could have received either the prescribed cephalosporin or another cephalosporin with a different R1 side chain.
-
Complex regional pain syndrome (CRPS) is evoked by conditions that may be associated with local and/or systemic inflammation. We present a case of long-standing CRPS in a patient with Ehlers-Danlos syndrome in which prolonged remission was attained by directing therapy toward concomitant small intestinal bacterial overgrowth, obstructive sleep apnea, and potential increased microglia activity. We theorize that cytokine production produced by small intestinal bacterial overgrowth and obstructive sleep apnea may act as stimuli for ongoing CRPS symptoms. CRPS may also benefit from the properties of low-dose naltrexone that blocks microglia Toll-like receptors and induces production of endorphins that regulate and reduce inflammation.
-
Pecs block and its variations have been used for various breast surgeries. We describe 2 cases of mastectomy and breast reconstruction by latissimus dorsi (LD) flap where regional analgesia was provided by a combination of ultrasound-guided Pecs-I block and serratus anterior plane block, a recently described technique in which local anesthetic is deposited in the plane between the LD and serratus anterior muscle. This resulted in excellent intraoperative and postoperative analgesia and a minimum of systemic analgesics. The described technique is safe to administer and provides good analgesia for breast reconstruction surgery by LD flap.