Percutaneous nephrostomy, feasibility of mid and anterior axillary line approach and its complications: an experience

Background: Nephrostomy performed as an emergency procedure to drain the obstructed calyceal system is a lifesaving procedure. Posterolateral approach is usually done to access the avascular plane of Brodel to avoid hemorrhage. This study evaluates the feasibility and complications in percutaneous nephrostomies placed at mid and anterior axillary line entry sites as it was found to be easier approach.Methods: A prospective study with 126 percutaneous nephrostomies performed with Ultrasound guidance, using single puncture technique and 8.5F pigtail catheter.  The complications rates were analyzed according to WHO guidelines. Results: The technical success rate was 98.4%. Three hemorrhagic complications (2.38%) were recorded without any major interventions. Increased incidence (11.9%) of transient hematuria was observed with five cases (3.9%) of infection at entry site. One case (0.79%) of peritoneal breech recorded with no significant intraperitoneal collection. Conclusions: Placement of Percutaneous Nephrostomy tube at mid or the anterior axillary line appears to be a feasible and easy approach, as its complications rates are within acceptable limits with an advantage of increased patient comfort.

Hemorrhagic complications and dental management of patients with anticoagulant therapy: case report

Introduction: There are different protocols for the management of anticoagulated patients that can be used when performing oral surgical procedures. Objective: To report the previous eva-luation and management of a hemorrhagic complication in the maxillofacial region in a patient undergoing oral anticoagulant therapy and the recommendations described in the literature for these patients. Clinical Case: Sixty-eight year old male patient, hospitalized in the cardiology unit due to heart failure, pending surgery for valve replacement. Treating physician requests evaluation for dental infection foci by a maxillofacial surgeon. Prior to medical examination and corresponding blood tests, four carious teeth are extracted, controlling hemostasis with local measures. During the night of the same day, the patient is referred again to the dental unit be-cause of an alveolorrhagia, being treated and controlled with new local measures; new standard blood tests are performed. Forty-eight hours later the patient presents an increase of volume in the right mandibular region compatible with hematoma and ecchymosis. It is decided to perform treatment, removing sutures, collagen and draining through the alveolus. Subsequently, new local measures are performed and the anticoagulant is suspended for 24 hrs. Conclusion: There are different care protocols for patients undergoing anticoagulant treatment in the literature, so each patient should be studied in advance to define what is the best therapeutic procedure to prevent complications.

The clinical efficacy in decreasing hemorrhagic complication by B-ultrasound combined with color Doppler ultrasound guidance in percutaneous nephrolithotomy / 中华泌尿外科杂志

Objective To evaluate the clinical significance of using B-ultrasound combined with color Doppler ultrasonography guidance in percutaneous nephrolithotomy ( PCNL) to decease the incidence of hemorrhagic complication.Methods A total of 323 patients with renal or urethral stones who had undergone PCNL were retrospectively categorized into 2 groups.Group 1 (147 patients) underwent PCNL with single B-ultrasound guidance while group 2 (176 patients) underwent PCNL with combined B-ultrasound and color Doppler ultrasound guidance. The clinical characteristics and complications, especially hemorrhagic complications in the two groups were recorded and compared.Results There were no statistical significances in age [ ( 53.2 ±12.9 ) years vs.( 54.7 ±9.1 ) years ] , hight [ ( 165.1 ±8.5 ) cm vs.( 164.6 ± 6.9) cm], weight[ (66.1 ±19.2) kg vs.(64.9 ±16.3) kg], stone burden [(680.5 ±56.4) mm2 vs. (654.0 ±76.9) mm2], operative time[(117.6 ±55.1) min vs.(121.4 ±54.3) min], stone-free rate (90.7%vs.91.3%), or postoperative hospital stay [(4.9 ±2.2)d vs.( 4.7 ±1.7 )d] between the two groups.In the B-ultrasound combined color Doppler ultrasound guidance group, the rate of blood transfusion (1.1%vs.3.4%) and super-selective embolization (0 vs.3.4%) was significantly lower than that of the single B-ultrasound guidance group.Besides, the incidents of renal arteriovenous fistula (0 vs.2.0%), pseudoaneurysm (0 vs.2.0%), and perirenal hematoma (0 vs.1.4%) were significantly lower in the B-ultrasound combined color Doppler ultrasound guidance group than that of the single B-ultrasound guidance group.Conclusion Using B-ultrasound combined color Doppler ultrasound guidance during PCNL resulted in the real-time detection and avoidance of the renal blood vessels during puncture and decreased the incidence of hemorrhagic complications.

Abcesso cerebral num doente com Rendu-Osler-Weber / Cerebral abscess in a patient with Rendu-Osler-Weber

A telangiectasia hemorrágica hereditária é uma doença familiar rara, descrita pela primeira vez no final do século 19, caracterizada por telangiectasias mucocutâneas e viscerais, e por malformações arteriovenosas. Manifestações neurológicas ocorrem em 8 a 12% dos doentes e resultam em mais de metade dos casos de malformações arteriovenosas pulmonares. A telangiectasia hemorrágica hereditária é uma das causas mais frequentes de abcessos cerebrais recorrentes, múltiplos e bilaterais, tendendo estes a ocorrerem na 3a para a 5a década. Apresentamos o caso de uma mulher de 88 anos admitida por prostração, febre e insuficiência respiratória, com a suspeita de metastização pulmonar de neoplasia oculta, cuja investigação revelou, entretanto, um abcesso cerebral secundário a malformações arteriovenosas pulmonares. Apesar da antibioterapia e da drenagem cirúrgica do abcesso, a paciente veio a falecer. O prognóstico após drenagem dos abcessos sem ressecção das lesões pulmonares é desfavorável, podendo sua elevada mortalidade refletir um atraso diagnóstico pela falta de reconhecimento dessa associação.

Hereditary hemorrhagic telangiectasia is a rare familial disorder, first described in the late 19th century characterized by multiple mucocutaneous and visceral telangiectases and arteriovenous malformations. Neurologic manifestations occur in 8 to 12% of patients and result from pulmonary arteriovenous malformations in 50% of cases. Hereditary hemorrhagic telangiectasia is one of the most frequent causes of recurrent, multiple and bilateral cerebral abscess and these tend to occur in the 3rd to 5th decade. We present the case of an 88-year-old woman admitted for prostration, fever and respiratory failure who was thought to have pulmonary metastasis of an unknown tumor but investigation revealed a brain abscess secondary to pulmonary arteriovenous malformations. Despite antibiotics and surgical drainage the patient died. The prognosis of brain abscess drainage without resection of the pulmonary lesions is not favorable. The high mortality of brain abscess in these patients may reflect a delay in diagnosis due to lack of recognition of this association.

Hemorrhagic complications following abdominal paracentesis in patients with acute-on-chronic liver failure / 中华传染病杂志

Objective The aim of this prospective observational study was to analyze the prevalence and the predictive factors of hemorrhagic events after abdominal paracentesis in patients with acute-on-chronic liver failure (ACLF).Methods ACLF patients who received at least one episode of abdominal paracentesis were prospectively enrolled between January 2010 to December 2013. Prevalences of intraperitoneal and abdomen hemorrhage complications were examined. t test was performed for continuous variables and chi-square test was performed for categorical variables.Binary Logistic regression was used to analyze the risk factors of hemorrhage.Results A total of 525 abdominal paracenteses were carried out on 185 ACLF patients within a 4-year period,with 289 (55 .0%)for diagnostic purpose and 236 (45 .0%)for therapeutic purpose.A total of 16 (3.0%)hemorrhagic complications were identified, with 4 cases of abdominal wall hematomas and 12 cases of intraperitoneal hemorrhage.Patients were divided into hemorrhage group and non-hemorrhage group according to this complication.Age,gender, Child-Pugh score,volume of ascitic fluid removed,underlying cirrhosis,platelet count and thrombin time were not significantly different between two groups (all P > 0.05 ).Patients with bleeding events had lower fibrinogen levels and higher prothrombin time,international normalized ratio,activated partial thromboplastin time and model for end-stage liver disease score (all P <0.05).After adjustment of other factors,multivariate regression analysis indicated that low fibrinogen level was the only independent predictor of hemorrhagic complication (OR=0.105,95%CI :0.018-0.608,P =0.012).Conclusion Low fibrinogen level is the independent predictor of severe hemorrhagic complications following paracenteses in patients with ACLF.

Intraparenchymal intracranial pressure monitoring in patients with acute liver failure / Monitoreo intraparenquimatoso de presión intracraneana en pacientes con falla hepática aguda

BACKGROUND: Elevated intracranial pressure (ICP) is a common cause of death in acute liver failure (ALF) and is determinant for decision-making regarding the timing of liver transplantation. The recommended type ICP monitoring device is controversial in ALF patients. Epidural devices had less risk of hemorrhagic complications, but they are less reliable than intraparenchymal ones. METHOD: Twenty-three patients with ALF were treated, and 19 of them received a liver transplant. Seventeen patients had ICP monitoring because of grade III-IV encephalopathy. All patients received fresh plasma (2-3 units) before and during placing the intraparenchymal device. RESULTS: Eleven cases (64.7 percent) had elevated ICP, and 6 patients (35.2 percent) had normal values. One patient (5.9 percent) had an asymptomatic small intraparenchymal haemorrhage <1cm³ in CTscan, which did not prevent the liver transplantation. CONCLUSION: In our experience, intraparenchymal ICP monitoring in patients with ALF seems to be an accurate method with a low risk of complications.

ANTECEDENTES: La presión intracraneana elevada (PIC) es una causa frecuente de muerte en la falla hepática aguda (FHA) y es determinante para la toma de decisiones respecto del momento del transplante hepático. El tipo de dispositivo para el monitoreo de OIC es controversial em los pacientes em FHA. Los dispositivos epidurales tienen menos riesgo de complicaciones hemorrágicas, pero son menos confiables que los intraparenquimatosos. MÉTODO: Veintitrés pacientes con FHA fueron tratados, y 19 de ellos recibieron un transplante hepático. diecisiete pacientes tuvieron monitoreo de PIC debido a encefalopatía grado III-IV. Todos los pacientes recibieron plasma fresco (2-3 unidades) antes y durante la colocación de la fibra intraparenquimatosa. RESULTADOS: Once casos (64.7 por ciento) tuvieron PIC elevada, y 6 pacientes (35.2 por ciento) tuvieron valores normales. Un paciente (5.9 por ciento) tuvo una pequeña hemorragia intraparenquimatosa asintomática <1cm³ en TAC, la cual no impidió el transplante hepático. CONCLUSIÓN: En nuestra experiencia, el monitoreo intraparenquimatoso de presión intracraneana en pacientes con FHA parece ser un método preciso y con bajo riesgo de complicaciones.