Bilateral diaphragmatic paralysis and Lyme neuroborreliosis. Ten-years of follow-up / Parálisis diafragmática bilateral y neuroborreliosis de Lyme. Diez años de seguimiento

Abstract Borrelia burgdorferi infection (Lyme disease) is one of the few identifiable causes of neuralgic amyotrophy (AN). Bilateral diaphragmatic paralysis is considered rare in borreliosis, and the pattern of long-term recovery of diaphragm function is also uncertain. Transdiaphragmatic pressure is the gold standard for diagnosing bilateral diaphragmatic paralysis, a study that has been reported on a few occasions. We pres ent a case of AN associated with borrelia infection and bilateral diaphragmatic paralysis that provides a detailed follow-up of the spirometric evolution, the maximum static pressures in the mouth, and the transdiaphragmatic pressure from the onset of symptoms and in the long term. This case allows us to know one of the possible evolutionary profiles of diaphragmatic dysfunction in AN due to borreliosis.

Resumen La infección por Borrelia burgdorferi (enfermedad de Lyme) es una de las pocas causas identificables de amiotrofia neurálgica. La parálisis diafragmática bilateral es considerada rara en la borreliosis y el patrón de recuperación a largo plazo de la función del diafragma también es incierto. La presión transdiafragmática es el patrón de oro para el diagnóstico de parálisis diafragmática bilateral, un estudio que ha sido informado en pocas ocasiones. Se presenta un caso de amiotrofia neurálgica asociado a infección por Borrelia y parálisis diafrag mática bilateral, que aporta un seguimiento detallado de la evolución espirométrica, de las presiones estáticas máximas en la boca y de la presión transdiafragmática desde el inicio de los síntomas y a largo plazo. Este caso permite conocer uno de los posibles perfiles evolutivos de la disfunción diafragmática en la amiotrofia neurálgica por borreliosis.

Hemidiaphragmatic paralysis with continuous interscalene block and diluted solutions of levobupivacaine / Bloqueo interescalénico y parálisis diafragmática con dosis diluidas de levobupivacaína

The continuous interscalene block represents the analgesic standard for shoulder surgery. However, the incidence of hemidiaphragmatic paralysis can reach up to 100% of cases. We hypothesized that more dilute local anesthetics would decrease the phrenic palsy at 24 hours. METHODS: Prospective series of patients undergoing arthroscopic shoulder surgery with continuous interscalene block. A 15-ml bolus of lidocaine 1%-levobupivacaine 0.25% plus an infusion of levobupivacaine 0.04% at an 8 mL/h rate plus 5 mL boluses on-demand with a 20-minutes lockout was used until discharge. Hemidiaphragmatic excursion was evaluated with M-mode ultrasound in the subcostal region before blocks, in the post-anesthetic unit, and at 24 h. The primary outcome was the presence of hemidiaphragmatic paralysis at 24 hours. Secondary outcomes included postoperative pain, amount of rescue boluses, postoperative opioids consumption, and side effects. RESULTS: Thirty patients were recruited and analyzed. The incidence of diaphragm paralysis at 24 h was 96.7%. The median [IQR] of pain at rest (patients with shoulder immobilizer) in a NRS from 0 to 10 at 0.5; 1; 3; 6; 12; 24; 48; 72 hours were 0 [0-0]; 0 [0-0]; 0 [0-0]; 0 [0-0]; 0 [0-0]; 0 [0-2]; 0 [0-2.5]; 0 [0-2], respectively. The median [IQR] consumption of LA boluses was 1.5 [0-7]. There were no postoperative morphine requirements. The most frequent side effect was Horner´s syndrome. CONCLUSIONS: Continuous interscalene block with 0.04% levobupivacaine provides adequate analgesia for arthroscopic shoulder surgery but does not prevent hemidiaphragmatic paralysis at 24 hours under the conditions of this study.

El bloqueo interescalénico representa el estándar analgésico para cirugía de hombro. No obstante, la incidencia de parálisis hemidiafragmática puede alcanzar 100% de los casos. Nuestra hipótesis es que infusiones con anestésicos locales más diluidos disminuirían la PHD 24 horas postbloqueo. MÉTODOS: Serie prospectiva de pacientes sometidos a cirugía artroscópica electiva de hombro con bloqueo interescalénico continuo. Un bolo de 15 mL de lidocaína 1%-levobupivacaína 0,5% más infusión postoperatoria de levobupivacaína al 0,04% a 8 ml/h más bolos a demanda de 5 mL con intervalo de 20 minutos hasta el alta. La excursión hemidiafragmática se evaluó con ultrasonido con transductor curvo 2-5 MHz en modo M en la región infracostal antes del bloqueo, en la unidad postanestésica y a las 24 h, antes del alta. El outcome primario fue la presencia de parálisis hemidiafragmática 24 horas postbloqueo. Los resultados secundarios incluyeron dolor postoperatorio, total de bolos de rescate, requerimiento de opioides postoperatorios y efectos secundarios. RESULTADOS: Treinta pacientes fueron reclutados y analizados. La incidencia de PHD a las 24 h fue 96,7%. La mediana [RIC] de dolor en reposo (pacientes con inmovilizador de hombro) medido en escala numérica de 0 a 10, a las 0,5; 1; 3; 6; 12; 24; 48; 72 horas fueron 0 [0-0]; 0 [0-0]; 0 [0-0]; 0 [0-0]; 0 [0-0]; 0 [0-2]; 0 [0-2.5]; 0 [0-2] respectivamente. La mediana [RIC] de consumo de bolos de rescate fue 1,5 [0-7]. No hubo pacientes con requerimientos de morfina postoperatoria. El efecto colateral más frecuente fue el síndrome de Horner. CONCLUSIONES: El bloqueo interescalénico continuo con levobupivacaína 0,04% proporciona analgesia postoperatoria adecuada, pero no evita la PHD a las 24 h en las condiciones de esta serie.

Hemidiaphragmatic paralysis after ultrasound-guided supraclavicular block: a prospective cohort study / Paralisia hemidiafragmática após bloqueio supraclavicular guiado por ultrassom: um estudo coorte prospectivo

Abstract Background and objectives: The frequent onset of hemidiaphragmatic paralysis during interscalene block restricts its use in patients with respiratory insufficiency. Supraclavicular block could be a safe and effective alternative. Our primary objective was to assess the incidence of hemidiaphragmatic paralysis following ultrasound-guided supraclavicular block and compare it to that of interscalene block. Methods: Adults warranting elective shoulder surgery under regional anesthesia (Toulouse University Hospital) were prospectively enrolled from May 2016 to May 2017 in this observational study. Twenty millilitres of 0.375% Ropivacaine were injected preferentially targeted to the "corner pocket". Diaphragmatic excursion was measured by ultrasonography before and 30 minutes after regional anesthesia. A reduction ≥25% in diaphragmatic excursion during a sniff test defined the hemidiaphragmatic paralysis. Dyspnoea and hypoxaemia were recorded in the recovery room. Predictive factors of hemidiaphragmatic paralysis (gender, age, weight, smoking, functional capacity) were explored. Postoperative pain was also analysed. Results: Forty-two and 43 patients from respectively the supraclavicular block and interscalene block groups were analysed. The incidence of hemidiaphragmatic paralysis was 59.5% in the supraclavicular block group compared to 95.3% in the interscalene block group (p < 0.0001). Paradoxical movement of the diaphragm was more common in the interscalene block group (RR = 2, 95% CI 1.4-3; p = 0.0001). A similar variation in oxygen saturation was recorded between patients with and without hemidiaphragmatic paralysis (p = 0.08). No predictive factor of hemidiaphragmatic paralysis could be identified. Morphine consumption and the highest numerical rating scale numerical rating scale (NRS) at 24 hours did not differ between groups. Conclusions: Given the frequent incidence of hemidiaphragmatic paralysis following supraclavicular block, this technique cannot be recommended for patients with an altered respiratory function.

Resumo Justificativa e objetivos: O aparecimento frequente de paralisia hemidiafragmática durante o bloqueio interescalênico restringe seu uso em pacientes com insuficiência respiratória. O bloqueio supraclavicular pode ser uma opção segura e eficaz. Nosso objetivo primário foi avaliar a incidência de paralisia hemidiafragmática após bloqueio supraclavicular guiado por ultrassom e compará-lo com o bloqueio interescalênico. Métodos: Os adultos agendados para cirurgia eletiva do ombro sob anestesia regional (Hospital Universitário de Toulouse) foram prospectivamente incluídos neste estudo observacional, de maio de 2016 a maio de 2017. Vinte mililitros de ropivacaína a 0,375% foram injetados, preferencialmente objetivando a interseção da primeira costela e da artéria subclávia. A excursão diafragmática foi medida por ultrassonografia antes e 30 minutos após a anestesia regional. Uma redução ≥ 25% na excursão diafragmática durante um sniff test definiu a paralisia hemidiafragmática. Dispneia e hipoxemia foram registradas na sala de recuperação. Fatores preditivos de paralisia hemidiafragmática (sexo, idade, peso, tabagismo, capacidade funcional) foram explorados. A dor pós-operatória também foi avaliada. Resultados: Quarenta e dois e 43 pacientes dos grupos bloqueio supraclavicular e bloqueio interescalênico, respectivamente, foram avaliados. A incidência de paralisia hemidiafragmática foi de 59,5% no grupo bloqueio supraclavicular em comparação com 95,3% no grupo bloqueio interescalênico (p < 0,0001). O movimento paradoxal do diafragma foi mais comum no grupo bloqueio interescalênico (RR = 2, 95% IC 1,4-3; p = 0,0001). Uma variação semelhante na saturação de oxigênio foi registrada entre os pacientes com e sem paralisia hemidiafragmática (p = 0,08). Nenhum fator preditivo de paralisia hemidiafragmática pôde ser identificado. O consumo de morfina e o maior escore na escala numérica (NRS) em 24 horas não diferiram entre os grupos. Conclusão: Devido à frequente incidência de paralisia hemidiafragmática após bloqueio supraclavicular, essa técnica não pode ser recomendada para pacientes com função respiratória alterada.

Successful Lung Transplantation in a Patient with Myasthenia Gravis

A 47-year-old man with myasthenia gravis (MG) was admitted for a lung transplant. He had bronchiolitis obliterans after allogeneic hematopoietic stem cell transplantation due to acute myeloid leukemia. MG developed after stem cell transplantation. Bilateral sequential lung transplantations and a total thymectomy were performed. The patient underwent right diaphragmatic plication simultaneously due to preoperatively diagnosed right diaphragmatic paralysis. A tracheostomy was performed and bilevel positive airway pressure (BiPAP) was applied on postoperative days 8 and 9, respectively. The patient was transferred to the general ward on postoperative day 12, successfully weaned off BiPAP on postoperative day 18, and finally discharged on postoperative day 62.

Successful Lung Transplantation in a Patient with Myasthenia Gravis

A 47-year-old man with myasthenia gravis (MG) was admitted for a lung transplant. He had bronchiolitis obliterans after allogeneic hematopoietic stem cell transplantation due to acute myeloid leukemia. MG developed after stem cell transplantation. Bilateral sequential lung transplantations and a total thymectomy were performed. The patient underwent right diaphragmatic plication simultaneously due to preoperatively diagnosed right diaphragmatic paralysis. A tracheostomy was performed and bilevel positive airway pressure (BiPAP) was applied on postoperative days 8 and 9, respectively. The patient was transferred to the general ward on postoperative day 12, successfully weaned off BiPAP on postoperative day 18, and finally discharged on postoperative day 62.

Clinical and laboratory diagnosis of congenital Zika virus syndrome and diaphragmatic unilateral palsy: case report / Diagnostico clínico e laboratorial do Zika vírus congênito e paralisia diafragmática unilateral: o relato de um caso

Abstract Introduction: several birth defects associated to congenital Zika virus infection have been reported, although the clinical features have not been fully characterized. Description: this is the first case report on unilateral diaphragmatic paralysis diagnosed on a neonate with congenital Zika confirmed by the examination of the amniotic fluid through polymerase chain reaction (ZIKV RT-PCR) and the examination of cerebrospinal fluid by serological test (IgM ZIKV-ELISA) after birth. The main manifestations detected by intrauterine ultrasound were: microcephaly, ventriculomegaly, intracranial calcifications, enlarged cisterna magna, increased amniotic fluid index and fetal akinesia syndrome. The newborn had acute respiratory failure in the first hours of life, requiring mechanical ventila-tion. The X- ray of the chest showed unilateral diaphragmatic paralysis and cardiomegaly. Discussion: diaphragmatic palsy in congenital Zika has not been previously reported, the etiopathogenic mechanisms of this event in congenital Zika virus needs to be elucidated.

Resumo Introdução: apesar de vários defeitos de nascimento associados à infecção congênita pelo Zika vírus terem sido descritos, o quadro clínico ainda não foi completamente caracterizado. Descrição: este é o primeiro relato de caso de paralisia diafragmática unilateral em um neonato com diagnóstico confirmado de Zika congênita pelo exame do líquido amniótico utilizando a reação da polimerase em cadeia (ZIKV PCR-RT) e pelo exame sorológico do líquido cefaloraquidiano (ZIKV IgM-ELISA), após o nascimento. As principais manifestações detectadas pela ultrassonografia intraútero no período gestacional foram: microcefalia, ventriculomegalia, calcificações intracranianas, cisterna magna alargada, aumento do índice de liquido amniótico e síndrome da acinesia fetal. O recém-nascido apresentou falência respiratória aguda nas primarias horas de vida, necessitando de ventilação mecânica. A radiografia de tórax realizada mostrou paralisia diafragmática unilateral e cardiomegalia. Discussão: a paralisia diafragmática na Zika congênita não havia sido previamente relatada, havendo a necessidade de investigação dos mecanismos etiopatogênicos dessa manifestação na infecção congênita pelo Zika vírus.

Parálisis diafragmática unilateral. Consecuencias del bloqueo del plexo braquial vía supraclavicular con ecografía / Unilateral diaphragmatic paralysis. Consequences of brachial plexus block by supraclavicular way with ecogram

Introducción: la anestesia regional ha experimentado importantes cambios en los últimos años, debido, principalmente, al uso de la electroestimulación y la ecografía. La parálisis unilateral del diafragma es una complicación secundaria al bloqueo del plexo braquial por vía supraclavicular con una incidencia del 50 al 67 por ciento. La introducción de la ecolocalización no está exenta de esta. Dar a conocer todos los pormenores a su alrededor para que sirvan de guía a generaciones futuras es un deber de cada investigador. Objetivo: incrementar el conocimiento del manejo de pacientes con bloqueos periféricos bajo el uso de la ultrasonografía y la importancia de su seguimiento. Caso clínico: paciente de 60 años con 82 kg de peso, el que se planificó operación electiva para retirar tumor del antebrazo. Antecedentes de cardiopatía isquémica hipertensiva tratada con la colocación de dos stent. Se decidió realizar bloqueo del plexo braquial por vía supraclavicular y se obtuvo un correcto bloqueo, pero se produjo una parálisis del diafragma unilateral con repercusión para el bienestar del paciente. Conclusiones: a pesar de usar la ultrasonografía para los bloqueos periféricos, se debe seguir una vigilancia estricta de cada paciente durante todo el acto quirúrgico(AU)

Introduction: Regional anesthesia has experienced major changes in recent years, particularly due to the use of electrostimulation and ecogram. The unilateral paralysis of the diaphragm is a secondary complication after blocking the supraclavicular brachial plexus, with an incidence of 50 to 67 percent. The introduction of echolocation is not exempt from this. Every scholar should provide all the details related to it, so that they can serve as a guide to the coming generations. Objective: To increase knowledge on the management of patients with peripheral nerve blocks under the use of ultrasound and the importance of following them. Clinical case: 60-year-old patient with 82 kg of weight, which was planned elective surgery to remove tumor from the forearm. The patient had antecedents of hypertensive ischemic heart disease treated with the placement of two stents. It was decided to lock the supraclavicular brachial plexus, obtaining a correct locking, but there was a unilateral paralysis of the diaphragm with implications for the patient's welfare. Conclusions: despite using ultrasound for peripheral nerve blocks, you must follow a strict monitoring of each patient throughout the surgical act(AU)

Is polysomnographic examination necessary for subjects with diaphragm pathologies?

OBJECTIVES: While respiratory distress is accepted as the only indication for diaphragmatic plication surgery, sleep disorders have been underestimated. In this study, we aimed to detect the sleep disorders that accompany diaphragm pathologies. Specifically, the association of obstructive sleep apnea syndrome with diaphragm eventration and diaphragm paralysis was evaluated. METHODS: This study was performed in Süreyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital between 2014-2016. All patients had symptoms of obstructive sleep apnea (snoring and/or cessation of breath during sleep and/or daytime sleepiness) and underwent diaphragmatic plication via video-assisted mini-thoracotomy. Additionally, all patients underwent pre- and postoperative full-night polysomnography. Pre- and postoperative clinical findings, polysomnography results, Epworth sleepiness scale scores and pulmonary function test results were compared. RESULTS: Twelve patients (7 males) with a mean age of 48 (range, 27-60) years and a mean body mass index of 25 (range, 20-30) kg/m2 were included in the study. Preoperative polysomnography showed obstructive sleep apnea syndrome in 9 of the 12 patients (75%), while 3 of the patients (25%) were regarded as normal. Postoperatively, patient complaints, apnea hypopnea indices, Epworth sleepiness scale scores and pulmonary function test results all demonstrated remarkable improvement. CONCLUSION: All patients suffering from diaphragm pathologies with symptoms should undergo polysomnography, and patients diagnosed with obstructive sleep apnea syndrome should be operated on. In this way, long-term comorbidities of sleep disorders may be prevented.

Delayed Onset Transient Diaphragmatic Paralysis after Pacemaker Implantation

A 77-year-old woman presented with exertional dyspnea six days after left pectoral pacemaker implantation. Chest radiography at presentation showed that her left diaphragm was elevated when compared to earlier films. A fluoroscopic sniff test confirmed left diaphragmatic paralysis. Thoracic computed tomography did not reveal any major vascular or lung parenchymal injury; however, phrenic nerve injury on direct needle puncture during the original surgery was suspected. The patient's small body size may have increased the risk of this injury. Delayed-onset unilateral diaphragmatic paralysis appears to be a rare complication of cardiac device implantation.

Diagnosis of diaphragmatic paralysis using ultrasound in a cervical herpes zoster patient: A case report

Herpes zoster is a varicella-zoster virus reactivation that is characterized by pain and rash. It can cause motor paresis on affecting muscles, but diaphragmatic paralysis is a rare complication. Methods of evaluation of diaphragmatic paralysis include plain radiography, fluoroscopy and electroneurography. The direct movement of diaphragmatic muscles on ultrasound can also be used to diagnose diaphragmatic paralysis. We reported a case of a 72-year-old woman who developed left hemidiaphragmatic paralysis after herpes zoster. The diaphragmatic paralysis occurred 3 weeks after appearance of a typical skin rash on the left C4-5 dermatomes. We diagnosed diaphragmatic paralysis using ultrasound.

Fatal neurotoxic envenomation following the bite of a greater black krait (Bungarus niger) in Nepal: a case report

Background Neurotoxic envenomation following bites by kraits (Bungarus species) is a leading cause of snakebite mortality in South Asia. Over a long time, this had been attributed only to one species, the common krait (Bungarus caeruleus). However, recent research has provided increasing evidence of the involvement of several krait species. Here, we report a fatal case of neurotoxic envenomation following the bite of a greater black krait (Bungarus niger) in Nepal. Case presentation A 33-year-old man was bitten in the outdoor corridor of his home in the eastern hills of Ilam district while handling a snake he thought to be non-venomous. He subsequently developed severe abdominal pain, frequent vomiting, and signs of neurotoxic envenomation leading to respiratory paralysis. The patient did not respond to Indian polyvalent antivenom given 4 h after the bite and died under treatment 8 h after the bite. This is the second time that a B. niger was observed in Nepal, the first documented case of envenomation by this species in the country and the sixth reported case worldwide. Conclusions Previous distribution records - from eastern India and western Nepal, from western hills in Nepal, and from lowland localities in India and Bangladesh - indicate risk of envenomation by B. niger throughout the low and intermediate elevations of Nepal up to at least 1,500 m above sea level. As very few people in Nepal bring killed snakes to healthcare centers and because there is a general belief among local people that there are no kraits in the hills, bites by B. niger are likely to be misdiagnosed and underreported.(AU)

Challenges of Transarticular Screw Fixation in Young Children: Report of Surgical Treatment of a 5-Year-Old Patient's Unstable Os-Odontoideum

Surgical procedures for atlantoaxial (C1–C2) fusion in young children are relatively uncommon. The purpose of this study was to report on a surgical treatment for a case of atlantoaxial instability caused by os-odontoideum in association with quadriparesis and respiratory paralysis in a 5-year-old girl. We present the patient's history, physical examination, and radiographic findings, describe the surgical treatment and a five year follow-up, and provide a literature review. The instability was treated by halo immobilization, followed by C1–C2 transarticular screw fixation using a computed tomography-based navigation system. At the five year follow-up, the patient had made a complete recovery with solid union. The authors conclude that C1–2 transarticular screw fixation is technically possible as in a case of atlantoaxial instability in a five-year-old child.

Evaluación de los músculos respiratorios en la parálisis diafragmática bilateral / Assessment of respiratory muscle strength in bilateral diaphragmatic paralysis

Measurement of respiratory muscle strength is useful in order to detect respiratory muscle weakness and to quantify its severity. Apropos of a patient with bilateral diaphragmatic paralysis, we review the clinical manifestations and methods for assessing the strength of the respiratory muscles. In patients with severe respiratory muscle weakness, vital capacity and total lung capacity are reduced but are a non-specific and relatively insensitive measure. Conventionally, inspiratory and expiratory muscle strength has been assessed by maximal inspiratory and expiratory mouth pressures sustained for one second (PIMax and PEMax). The sniffmanoeuvre is natural and probably easier to perform. Sniff pressures are more reproducible and useful measure of diaphragmatic strength. However, the PIMax-PEMax and sniff manoeuvres are volition dependent, and submaximal efforts are most likely to occur in patients who are ill or breathless. Non-volitional tests include measurements of twitch esophageal, gastric and transdiaphragmatic pressure during bilateral electrical and magnetic phrenic nerve stimulation. Electrical phrenic nerve stimulation is technically difficult and is also uncomfortable and painful. Magnetic phrenic nerve stimulation is less painful and transdiaphragmatic pressure is reproducible in normal subjects. Systematic clinical evaluation and additional laboratory tests allow the diagnosis in most patients with respiratory muscle weakness.

La evaluación de la fuerza de los músculos respiratorios permite diagnosticar y cuantificar la gravedad de la debilidad muscular en diferentes enfermedades. A propósito de un paciente con parálisis diafragmática bilateral, hemos revisado el cuadro clínico y los procedimientos diagnósticos para evaluar la fuerza de los músculos respiratorios. En los pacientes con debilidad muscular respiratoria severa, disminuye la capacidad vital y la capacidad pulmonar total, pero es una medida inespecífica y relativamente insensible. Tradicionalmente, la fuerza muscular respiratoria es evaluada midiendo la presión inspiratoria y espiratoria máximas en la boca sostenidas durante un segundo (PIMax y PEMax). La medición de la presión inspiratoria máxima en la nariz (SNIP) es una maniobra natural, más simple de medir y más reproducible, siendo útil en la evaluación de la fuerza diafragmática. Sin embargo, estas técnicas no invasivas son operador dependiente, por lo tanto, esfuerzos submáximos es más probable que ocurran en pacientes graves o con disnea. Las mediciones de las presiones esofágica, gástrica y transdiafragmática mediante estimulación eléctrica o magnética del nervio frénico no son dependientes de la voluntad y son más confiables. Sin embargo, la estimulación eléctrica del nervio frénico es técnicamente difícil y puede ser incómoda y dolorosa. La estimulación magnética del nervio frénico es menos dolorosa y la medición de la presión transdiafragmática es reproducible en sujetos normales. La evaluación clínica sistemática y los exámenes de laboratorio complementarios permiten establecer el diagnóstico en la mayoría de los pacientes con debilidad de los músculos respiratorios.

Parálisis diafragmática en el post operatorio de cirugía cardiovascular, trasplantes cardíaco y pulmonar / Diaphragmatic paralysis in the postoperative period after cardiovascular surgery, and heart and lung transplantation

Objetivo principal: Describir la incidencia, evolución y tratamiento de los pacientes con parálisis diafragmática (PD) en los postoperatorios (POP) de cardiopatías congénitas (CC), trasplante cardiaco (TC) y trasplante pulmonar (TP) en la Unidad de Cuidados Intensivos 35 (UCI 35) del Hospital de Pediatría Juan P. Garrahan. Método: Se estudiaron 43 pacientes POP de CC, TC y TP que cursaron con PD durante los años 2010 al 2013. Se estudiaron datos demográficos como edad expresada en meses, sexo, peso en kilos, la existencia de sindromes genéticos, internación prequirúrgica, mala condición previa presencia de cirugía, circulación extracorpórea (CEC), días en ARM, fracaso de extubación, plicatura diafragmática, defecto residual cardiaco, obstrucción de VAS post extubación, atelectasias (ATL), episodios en ventilación no invasiva (VNI), traqueotomía (TQT), entre otros días de internación, tipo de egreso y sobrevida. Resultados: La incidencia de PD fue del 2,35%, de los 43, 22 fueron niñas, la edad M = 9 meses (0,5-204), con un peso M = 6,8 (2,3-65); 34 pacientes POP de CC, 4 POP de TC y 5 de TP. El 95% de la cirugías fue con CEC, 18 pacientes tenían cirugía previa, 21 con mala condición preoperatoria, los días de ARM M = 10 (0-109), el 55% tuvo al menos un fracaso de extubación, se realizaron 21 plicaturas, dentro de los 5 días del diagnóstico de PD en un 50%, se practicaron 6 TQT, el 83% de los pacientes tuvo por lo menos un episodio en VNI, la sobrevida al alta, de 88%. Conclusiones: Si bien la PD es poco frecuente en nuestra población, aumenta considerablemente la morbilidad de estos pacientes.

Suicidal Death by Nicotine Poisoning / 대한법의학회지

Nicotine is a water-soluble alkaloid extracted from tobacco plants, and most frequently encountered in snuff, chewing tobacco, cigarettes, cigars and pipe tobacco or in a limited number of pesticides. Nicotine overdose or poisoning might be serious or fatal and lead to death; caused by cardiovascular arrest, respiratory muscle paralysis, and/or central respiratory failure due to its toxic effect. Suicide by nicotine ingestion has been rarely reported due to emetic response. We present a case of suicidal nicotine poisoning. A 56-year-old man was found dead and the postmortem examination revealed no injury or disease. We confirmed a high concentration of nicotine in the toxicological test. Through scene investigation, we determined this case as a suicidal nicotine poisoning.

Postoperative diaphragmatic paralysis after cardiac surgery in children: incidence, diagnosis and surgical management / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Cardiac surgery for congenital heart disease covers a wide spectrum from simple to complex cardiac and extracardiac malformations. Innovations in pediatric cardiac surgery and perioperative care over the past decades have allowed surgical correction or at least palliation in almost all complex congenital heart defects in the first years of life. Diaphragmatic paralysis (DP) due to phrenic nerve injury after congenital cardiac surgery is an important respiratory complication resulting with respiratory insufficiency, lung infections, prolonged hospital stay time and even death.</p><p><b>METHODS</b>Between April 2001 and December 2010, among patients undergoing cardiac surgery for congenital heart disease, postoperative DP was diagnosed in 47/10 200 (0.46%) patients. Diaphragmatic placation was performed in 37/47 patients. DP was suspected in children who failed to wean from mechanical ventilation or in those with persistent respiratory distress when there is no cardiac cause. Decreased respiratory sounds in auscultation, paradoxical breathing during spontaneous ventilation and elevated hemidiaphragm on chest X-ray led us to use fluoroscopy, ultrasound and/or electromyogram (EMG). When chest X-rays did not have a diagnostic value in patients with persistent respiratory distress, bilateral DP was suspected and immediate fluoroscopy of EMG was performed for diagnosis. In all patients, diaphragmatic placation was performed using a thoracic approach, through the sixth or seventh intercostals space with lateral thoracotomy.</p><p><b>RESULTS</b>A total of 47 patients (21 females and 26 males) with a median age of 7.21 months (range 0.27-71 months) were diagnosed DP after cardiac surgery. The incidence of DP was 0.46% after cardiac surgery. The paralysed hemidiaphragm was left side in 26/47 (55.3%), right side in 17/47 (36.2%) and bilateral in 4/47 (8.5%) cases. The assisted ventilation time after cardiac surgery was (450±216) (116-856) hours. The median time from cardiac surgery to surgical placation was (24±14) (5-56) days. No patient died in this study. The follow-up period was (26.2±16.8) months. The position of the plicated diaphragm was normal on chest X-ray, in all plicated survivors within the 1st, 6th and 12th months after discharge.</p><p><b>CONCLUSIONS</b>DP caused by phrenic nerve injury during surgical intervention for congenital heart disease is an important risk factor in terms of morbidity during the postoperative period. Diaphragmatic placation appears a good option, especially in newborns and small children, to wean patients from mechanical ventilation and to prevent long-term side effects of mechanical ventilation.</p>

Ventilação elétrica: indicações e aspectos técnicos do implante cirúrgico do marca-passo de estimulação diafragmática / Electric ventilation: indications for and technical aspects of diaphragm pacing stimulation surgical implantation

OBJETIVO: Pacientes com lesão medular cervical alta em geral são dependentes de ventilação mecânica, que, embora salve vidas, está associada a complicações e redução da expectativa de vida devido a infecções respiratórias. A estimulação do diafragma por marca-passo, às vezes chamada de ventilação elétrica, induz a inspiração por estimulação dos músculos inspiratórios. Nosso objetivo foi destacar as indicações e alguns aspectos da técnica cirúrgica empregada no implante laparoscópico dos eletrodos, assim como descrever cinco casos de pacientes tetraplégicos submetidos à técnica. MÉTODOS: A seleção dos pacientes envolveu estudos de condução do nervo frênico por via transcutânea para determinar se os nervos estavam preservados. A abordagem cirúrgica foi laparoscopia clássica, com quatro trocartes. A técnica foi iniciada com o mapeamento elétrico para encontrar os "pontos motores" (pontos de contração máxima do diafragma). Se o mapeamento era bem-sucedido, dois eletrodos eram implantados na face abdominal de cada lado do diafragma para estimular ramos do nervo frênico. RESULTADOS: Dos cinco pacientes, três e um, respectivamente, eram capazes de respirar somente com o uso do marca-passo por períodos superiores a 24 e 6 h, enquanto um não era capaz. CONCLUSÕES: Embora seja necessário um acompanhamento mais longo para chegar a conclusões definitivas, os resultados iniciais são promissores, pois, no momento, a maioria dos nossos pacientes pode permanecer sem ventilação mecânica por longos períodos de tempo.

OBJECTIVE: Patients with high cervical spinal cord injury are usually dependent on mechanical ventilation support, which, albeit life saving, is associated with complications and decreased life expectancy because of respiratory infections. Diaphragm pacing stimulation (DPS), sometimes referred to as electric ventilation, induces inhalation by stimulating the inspiratory muscles. Our objective was to highlight the indications for and some aspects of the surgical technique employed in the laparoscopic insertion of the DPS electrodes, as well as to describe five cases of tetraplegic patients submitted to the technique. METHODS: Patient selection involved transcutaneous phrenic nerve studies in order to determine whether the phrenic nerves were preserved. The surgical approach was traditional laparoscopy, with four ports. The initial step was electrical mapping in order to locate the "motor points" (the points at which stimulation would cause maximal contraction of the diaphragm). If the diaphragm mapping was successful, four electrodes were implanted into the abdominal surface of the diaphragm, two on each side, to stimulate the branches of the phrenic nerve. RESULTS: Of the five patients, three could breathe using DPS alone for more than 24 h, one could do so for more than 6 h, and one could not do so at all. CONCLUSIONS: Although a longer follow-up period is needed in order to reach definitive conclusions, the initial results have been promising. At this writing, most of our patients have been able to remain ventilator-free for long periods of time.

Evaluación por imágenes del diafragma en el niño / Image evaluation of diaphragm in children

The anatomy, embriology andfunctions of the neonate 's diaphragm, as well as its anatomical and functional oddities were reviewed. And, in a deeper way, imaging studies were also reviewed; these have an important role in functional and anatomic evaluation of the diaphragm, each one with its own advantages and limitations. Chest X-rays allow an anatomic two dimensional evaluation of the diaphragm and constitutes the first approach in the study of diaphragm pathology in children; hence, the normal anatomy and the most common pathological signs are reviewed. Digestive tube studies using contrast media still are the best choice for diagnosis of hiatal hernia and of herniation through the foramen of Morgagni, where the colon is ascended. Ultrasound use is highlighted for the evaluation of diaphragmatic motility, as well as some of its advantages over fluoroscopy, which is and has been the method of choice in the diagnosis of diaphragmatic paralysis in children. Multiplanar images are the most complete method for the anatomic evaluation of the diaphragm, since they show its spatial orientation and allow the detailed evaluation of those pahologies where the anatomy is altered, such as diaphragmatic hernias, trauma and tumors.

Revisamos la embriología, anatomía y funciones del diafragma, sus particularidades anatómicas y funcionales en los neonatos y, en forma más profunda, los estudios por imágenes, que en la actualidad tienen un importante rol en su evaluación anatómica y funcional, cada uno de ellos con sus ventajas y limitaciones. La radiografía de tóraxpermite una evaluación anatómica en dos planos del diafragma y constituye la primera aproximación en el estudio de la patología del diafragma en los niños, por lo que se describe la anatomía normal y los signos de las patologías más frecuentes. Los estudios contrastados del tubo digestivo siguen siendo de elección para el estudio de las hernias hiatales y hernias de Morgagni en donde está ascendido el colon. Destacamos el uso del ultrasonido en la evaluación de la motilidad diafragmática, y algunas de sus ventajas sobre la fluoroscopia, que es y ha sido el método de elección en el diagnóstico de la parálisis diafragmática en los niños. Las imágenes multiplanares son un método más completo en la evaluación anatómica del diafragma, muestran mejor su orientación espacial y permiten la evaluación detallada de las patologías donde la anatomía está alterada, como hernias diafragmáticas congénitas, trauma y tumores.

Síndrome intermedio en intoxicación aguda por organofosforados: reporte de caso / Intermediate syndrome in acute organophosphorus poisoning: a case report

La intoxicación con organofosforados es una de las más frecuentes en seres humanos, debido a la amplia disponibilidad de estas sustancias en el mercado de los países en desarrollo. Además de las crisis colinérgicas, esta intoxicación puede generar cuadros de compromiso neuromuscular después de la exposición aguda. Entre ellos, se encuentra la parálisis tipo dos o síndrome intermedio, una alteración que produce una alta morbimortalidad porque compromete los músculos de la caja torácica, lo que lleva a una parálisis respiratoria. Este artículo presenta una paciente de 16 años, remitida a la Clínica Universitaria Bolivariana (CUB), tras una intoxicación con organofosforados, quien fue ingresada a urgencias en un síndrome colinérgico agudo. Después de la administración de atropina, desarrolla como complicación temprana el síndrome intermedio, lo que obligó al manejo con ventilación mecánica durante la fase de compromiso ventilatorio. Durante la recuperación, se evidencia que el compromiso neuromuscular involucra las cuatro extremidades, el cual se va recuperando sin ningún tipo de intervención farmacológica, como fenómeno característico en este tipo de compromisos.

Organophosphate poisoning is one of the most frequent intoxications in human beings, due to the wide availability of these substances in the developing countries; besides the cholinergic crisis, this poisoning can cause neuromuscular compromise after acute exposition. Among them, there is paralysis type two or intermediate syndrome, a rare disorder that can increase morbidity and mortality if it appears, due to the compromise of the rib cage muscles, leading to a respiratory paralysis.This article presents a 16 years old female, who was refered to the "Clinica Universitaria Bolivariana" (CUB) after an organophosphorus poisoning and was admitted to the emergency room with an acute cholinergic syndrome. After antidotal treatment with atropine, she developed the intermediate syndrome as an acute complication that was managed with mechanical ventilation during the ventilatory compromise. During the recovery phase, it is evident that the neuromuscular compromise involves the four limbs, but it begun to recover gradually without any pharmacological intervention, a phenomenon that is characteristic of such liabilities