Brachial plexus lesions following cardiac surgery with median sternotomy and cannulation of the internal jugular vein

Peripheral neuropathy after extra-corporeal membrane oxygenation therapy in children: A case report

RATIONALE

In recent years, the use of extracorporeal membrane oxygenation (ECMO) treatment for pediatric patients with cardiorespiratory failure has increased, with emphasis being given to the prevention of complications in ECMO-treated patients. Several studies have reported ECMO-related central nervous system complications, such as intracranial hemorrhage, cerebral infarction, and seizure. However, few cases of peripheral nerve injury have been reported in ECMO-treated adults; there have also been no reported cases of peripheral nerve injury in the pediatric population.

PATIENT CONCERNS

Two pediatric patients aged 16 and 6 experienced motor weakness in the extremities after the insertion of ECMO equipment.

DIAGNOSES

They were diagnosed with peripheral nerve injuries through an electrodiagnostic study that showed femoral/sciatic neuropathies and brachial plexopathy. Arteriography and doppler sonography was performed to find the cause of peripheral nerve injury, and this may be the results of vascular compromise and compressive injuries, respectively.

INTERVENTIONS

Surgical embolectomy was performed to remove thrombus in one patient. Two patients received orthosis, and physical therapy and occupational therapy were performed to prevent contracture and improve strength and functional use.

OUTCOMES

Two pediatric patients showed a gradual improvement in motor power and function.

LESSONS

Through this case report, we present rare ECMO-related complications and emphasize the importance of early diagnosis and monitoring of peripheral nerve injury in ECMO-treated children.

Evoked Potentials during Cardiac and Major Vascular Operations

Somatosensory evoked potentials are widely used in spine surgery to prevent injury to the spinal cord. However, their application in cardiac and major vascular surgery is largely unappreciated. This paper will review the unique stresses placed on peripheral nerves, spinal cord, and brain during these operations. In addition, the potential benefits of perioperative somatosensory evoked potentials monitoring are described in detail.

Brachial plexus injury associated with extracorporeal membrane oxygenation

INTRODUCTION

Extracorporeal membrane oxygenation (ECMO) is a cardiopulmonary support system. We present 2 patients of ECMO-related brachial plexus injury.

METHODS

Patients were selected from a registry of 154 patients treated with ECMO from January 2002 to September 2011.

RESULTS

Five patients had unilateral arm weakness after the initiation of ECMO therapy. There was no neurological examination or electrophysiological testing data available for 3 patients. Diagnosis of brachial plexus injury was confirmed in 2 patients, one based on neurological examination and one based on electrophysiological testing.

DISCUSSION

Axillary artery cannulation resulting in hematoma formation was identified as a probable risk factor for brachial plexus injury in our 2 patients.

Pain symptoms accompanying chronic poststernotomy pain: a pilot study

OBJECTIVE

Despite the technical developments in surgical procedures, chronic poststernotomy pain (CPSP) is still very common. Many theories for its cause have been proposed in the literature, but the etiology is still not clear. Pain along the sternal scar and in the upper extremities (sometimes accompanied with paresthesia) persists in about 30% of cases. These symptoms have been regarded as two separate complications. This study investigated all pain symptoms in patients following sternotomy.

DESIGN

Retrospective pilot study.

SETTING

Outpatient clinic at the Leiden University Medical Center.

PATIENTS

A cohort of patients who underwent open heart surgery by median sternotomy between January 1, 2004 and January 1, 2006.

INTERVENTIONS

A questionnaire was completed by 631 patients, and a selected sample of 277 patients was examined for pain of the head, neck, back, and chest and upper extremities.

OUTCOME MEASURES

All pain locations were compared in two groups: 189 patients with sternal pain and 88 patients without sternal pain.

RESULTS

We found that pain and muscular tenderness in the investigated areas unrelated to the chest wall incision were significantly more common in patients with sternal pain compared to the nonsternal pain group. No surgical or demographic factors with the exception of female gender were consistent predictors of sternal pain.

CONCLUSION

CPSP is an extensive pain syndrome. Sternal pain is frequently accompanied by pain of the head, neck, back, and upper extremities. Further research on the possible etiology is warranted.

[The involvement of the brachial plexus in cardiac surgery with median sternotomy for the revascularization of the myocardium: clinical evaluation]

To evaluate the involvement of brachial plexus in cardiac surgery with median sternotomy for the revascularization of the myocardium 113 patients (87 men and 26 women) were clinically examined in the preoperative and between the fifth and eight post-operative days. The internal thoracic artery was used in 65 of the 113 patients. The electroneuromyography was not effected in any of the patients. A lesion of the brachial plexus was found in three patients though the internal thoracic artery was used in only one patient. We believe that factors such as posture of the patient, hypothermia, thoracic braces and use of the internal thoracic artery are relevant in the lesions. Hence one must be attentive to all the factors mentioned above so as to avoid or minimize the lesions.

[Claude Bernard-Horner syndrome and its opposite, Pourfour du Petit syndrome, in anesthesia and intensive care]

OBJECTIVE

To analyse cases of Horner's syndrome (HS) and its opposite, Pourfour du Petit's syndrome (PPS), occurring in anaesthesia and intensive therapy with consideration of the data of current literature.

DATA SOURCES

For this paper we have reviewed the French, English and German literature published in anaesthesia and intensive care journals using Medline search and the current textbooks.

STUDY SELECTION

All observational studies on these syndromes, whether clinical cases or letters to the editor, form the basis for this article.

DATA EXTRACTION

The articles were analysed mainly with regard to diagnosis, therapy and prognosis of syndromes due to iatrogenic causes.

DATA SYNTHESIS

HS is caused by a paralysis of the ipsilateral sympathetic cervical chain and includes a ptosis of the upper eyelid, a slight elevation of the lower lid, a sinking of the eyeball, a constriction of the pupil, a narowing of the palpebral fissure, a nasal stuffiness associated with anhidrosis, and flushing of the affected side of the face. Regional anaesthesia (intra-oral anaesthesia, brachial plexus block, epidural anaesthesia whether by thoracic, lumbar or caudal approach, as well as interpleural analgesia) is the main anaesthetic cause for HS. HS due to the effect of a local anaesthetic is transient, it can precede a high spinal block and a cardiovascular collapse. HS from puncture of the internal jugular vein is most often permanent. When transient, HS regresses within 3 months after puncture. Other causes of HS include intraoperative posture, pleural drain, neck surgery, neck trauma. A mydriatic collyrium, such as phenylephrine, resolves ptosis for less than 1 hour and results in blurred vision from pupillary dilation. Major ptosis requires surgery. PPS is the reciprocal HS and is caused by a stimulation of the ipsilateral sympathetic cervical chain. PPS can precede HS. It carries a risk for conjunctivitis, keratitis and epiphora in case of major exophthalmia. PPS is often reported as an unilateral mydriasis. PPS has the same causes as HS. Myotic collyriums are relatively inefficient. Major lid retraction requires a tarsorraphy, pomades and nocturnal lid occlusion. A part of HS and most PPS occurring in anaesthesia and intensive care remain unrecognized or are recognized with delay, especially if they remain minor and transient or when they occur in unconscious patients, in horizontal posture.