Tracheobronchial malacia and stenosis in children in intensive care: bronchograms help to predict oucome.

BACKGROUND: Severe tracheobronchial malacia and stenosis are important causes of morbidity and mortality in children in intensive care, but little is known about how best to diagnose these conditions or determine their prognosis. METHODS: The records of all 62 children in whom one or both of these conditions had been diagnosed by contrast cinetracheobronchography in our intensive care unit in the period 1986-95 were studied. RESULTS: Seventy four per cent of the 62 children had congenital heart disease; none was a preterm baby with airways disease associated with prolonged ventilation. Fifteen of the children had airway stenosis without malacia; three died because of the stenosis and two died from other causes. Twenty eight of the 47 children with malacia died; only eight children survived without developmental or respiratory handicap. All children needing ventilation for malacia for longer than 14 consecutive days died if their bronchogram showed moderate or severe malacia of either main bronchus (15 cases), or malacia of any severity of both bronchi (three additional cases); all children needing ventilation for malacia for longer than 21 consecutive days died if their bronchogram showed malacia of any severity of the trachea or a main bronchus (three additional cases). These findings were strongly associated with a fatal outcome (p<0.00005); they were present in 21 children (all of whom died) and absent in 26 (of whom seven died, six from non-respiratory causes). They had a positive predictive value for death of 100%, but the lower limit of the 95% confidence interval was 83.9% so up to 16% of patients meeting the criteria might survive. CONCLUSION: In this series the findings on contrast cinetracheobronchography combined with the duration of ventilation provided a useful guide to the prognosis of children with tracheobronchomalacia. The information provided by bronchoscopy was less useful.

Spermatic-cord block improves analgesia for day-case testicular surgery.

OBJECTIVE: To assess whether the use of a spermatic-cord block contributes any additional analgesia to that of a conventional analgesic regimen in day-case testicular surgery. PATIENTS AND METHODS: In a randomized, double-blind controlled study, 48 patients undergoing day-case testicular surgery received general anaesthesia together with fentanyl and diclofenac for analgesia. In addition, 22 of these patients received 10 mL of 0.5% plain bupivacaine into the spermatic cord at the conclusion of surgery. Visual-analogue pain scores were recorded for each group over the following 24 h. RESULTS: The visual-analogue pain scores were significantly lower in the immediate recovery period in patients receiving the spermatic-cord block. CONCLUSION: The spermatic-cord block reduced discomfort in the immediate post-operative period in patients undergoing testicular surgery and the procedure should be encouraged to improve the quality of post-operative pain management in such procedures.

Hyperventilation-induced unconsciousness during labour.

We report the development of unconsciousness caused by hyperventilation in an otherwise healthy woman in labour. Extradural analgesia resulted in restoration of full consciousness and normal respiratory state. The pathophysiology of hyperventilation and aspects of respiratory physiology in pregnancy are discussed.

Paradoxical cerebral embolism originating from thrombus in tumour veins as presenting manifestation of retroperitoneal liposarcoma.

The coincidence of pulmonary and systemic emboli suggests paradoxical embolism. We present the case of a young man in whom a blood clot travelled from the veins in a retroperitoneal liposarcoma via a patent foramen ovalis to the systemic arterial circulation. Young patients with embolic disease but no obvious source of thrombus may have underlying neoplastic disease. Venous thrombosis is a frequent complication of neoplastic disease. Arterial embolism associated with neoplasm is, however, not widely recognised.