RESUMO
Epidural analgesia or anesthesia is a common procedure for pain relief, especially in obstetrics. Pneumorrhachis and pneumothorax are rare complications of epidural analgesia. They are considered asymptomatic entities but have recently caused increased morbidity and mortality. As the use of epidural analgesia and anesthesia increased significantly in the last decade, clinicians must be aware of this entity. This is a case report of pneumorrhachis causing pneumothorax and pneumomediastinum leading to respiratory distress. Case: A 26-year-old obese primigravida at 37 weeks' gestation and with failure of progression of labor underwent lower segment cesarean section under epidural anesthesia. The procedure including the delivery of fetus was uneventful. In the post-anesthesia care unit, the patient became tachypneic, and her oxygen saturation was low despite supplemented oxygen by face mask and adequate analgesia. She was afebrile and was admitted to the surgical intensive care unit (SICU) for further management. In the SICU, incentive spirometry was initiated, and analgesia with intravenous fentanyl was given. Her echocardiogram was normal. Computer tomographic examination ruled out pulmonary embolism but showed pneumorrhachis with extension into the mediastinum and right apical pneumothorax. She was hemodynamically stable. In the next two days, her tachypnea settled, and the oxygen saturation improved to normal. On the third day, she was transferred to the ward and discharged home from there. She was followed up in the outpatient clinic after one and four weeks and was doing well, and her repeat imaging studies were normal. Conclusion: Epidural analgesia can lead to pneumorrhachis and can cause pneumothorax leading to respiratory distress.
RESUMO
Cardiac injury after blunt trauma is common but underreported. Common cardiac trauma after the blunt chest injury (BCI) is cardiac contusion; it is very rare to have cardiac valve injury. The mitral valve injury during chest trauma occurs when extreme pressure is applied at early systole during the isovolumic contraction between the closure of the mitral valve and the opening of the aortic valve. Traumatic mitral valve injury can involve valve leaflet, chordae tendineae, or papillary muscles. For the diagnosis of mitral valve injury, a high index of suspicion is required, as in polytrauma patients, other obvious severe injuries will divert the attention of the treating physician. Clinical picture of patients with mitral valve injury may vary from none to cardiogenic shock. The echocardiogram is the main diagnostic modality of mitral valve injuries. Patient's clinical condition will dictate the timing and type of surgery or medical therapy. We report a case of mitral valve and pericardial injury in a polytrauma patient, successfully treated in our intensive care unit.
RESUMO
BACKGROUND: Necrotizing fasciitis (NF) is a surgical emergency. It is a rapidly progressing infection of the fascia and subcutaneous tissue and could be fatal if not diagnosed early and treated properly. NF is common in the groin, abdomen, and extremities but rare in the neck and the head. Cervical necrotizing fasciitis (CNF) is an aggressive infection of the neck and the head, with devastating complications such as airway obstruction, pneumonia, pulmonary abscess, jugular venous thrombophlebitis, mediastinitis, and septic shock associated with high mortality. AIM: To assess the presentation, comorbidities, type of infection, severity of disease, and intensive care outcome of CNF. METHODS: Medical records of the patients treated for NF in the surgical intensive care unit (SICU) from January 1995 to February 2005 were reviewed retrospectively. RESULTS: Out of 94 patients with NF, 5 (5.3%) had CNF. Four patients were male. The mean age of our patients was 41.2 +/- 14.8 years. Sixty percent of patients had an operative procedure as the predisposing factor and 80% of patients received nonsteroidal anti-inflammatory drugs (NSAIDs). The only comorbidity associated was diabetes mellitus (DM) in 3 patients (60%). Sixty percent of the cases had type1 NF. Mean sequential organ failure assessment (SOFA) score on admission to the ICU was 8.8 +/- 3.6. All patients had undergone debridement at least two times. During the initial 24 h our patients received 5.8 +/- 3.0 l of fluid, 2.0 +/- 1.4 units of packed red blood cells (PRBC), 4.8 +/- 3.6 units of fresh frozen plasma (FFP), and 3.0 +/- 4.5 units of platelet concentrate. The mean number of days patients were intubated was 5.2 +/- 5.1 days and the mean ICU stay was 6.4 +/- 5.2 days. Sixty percent of cases had multiorgan dysfunction (MODS) and one patient died, resulting in a mortality rate of 20%. CONCLUSION: According to our study, CNF represents around 5% of NF patients. CNF was higher among male patients and in patients with history NSAIDs and dental surgeries. Type 1 NF was more common and DM was the only comorbid condition seen in this limited number of patients. The low mortality may be due to the early diagnosis and aggressive surgical treatment combined with optimal supportive intensive care management.
