Anesthesia and surgery in very precarious conditions. Clinical cases

We performed herniorrhaphy on 21 children (4 of them infants) and 3 adults, in very precarious conditions, in a hospital in a economically depressed area of the Democratic Republic of Congo. Anesthesia technique used in adults was subarachnoid and intravenous and intramuscular ketamine in children. Ketamine is an irreplaceable anesthetic in many parts of the world without resources, where the minimum safety means are not available. Knowing the simple anesthetic techniques, but with less risk, can also be useful in resourceful places, in unexpected situations. Greater solidarity is needed, both from anesthesia societies and from anesthesiologists, to alleviate the great deficiencies in well-trained professionals and means in places without resources.

P1249 Straight from the heart

Introduction

Infective endocarditis (IE) remains a diagnostic and therapeutic challenge and is still associated with high mortality. Systemic complications are frequently present, and an adequate assessment and management are needed.

Purpose

Our aim is to show the importance of an early recognition of IE complications.

Clinical case

We present a case of 54 years old women with a past medical history unremarkable. The patient presented to the hospital with high fever and was admitted with a diagnosis of a psoas abscess and staphilococus aureus bacteremia. After one week of antibiotic treatment the patient was transferred to an intensive care unit due to septic shock and respiratory failure. The patient needed to be intubated and ventilated and was on treatment with vancomycin and meropenem. During admission, several infectious loci were identified, including cerebral and pulmonar involvement. An echocardiography identified mild mitral regurgitation, moderate tricuspid regurgitation and confirmed the presence of two vegetations, one in tricuspid valve with 30mm and one in mitral valve with 5mm. Nevertheless, the patient improved clinically. After 15 days of treatment, the patient was extubated and was transferred to the cardiology ward for follow-up. Although clinically stable and without any complain, repeated echocardiographic evaluation identified left ventricular apical aneurysm and partial resolution of vegetations. A coronariography was performed and did not identified any coronary lesion. A magnetic resonance confirmed the ischemic aetiology of the lesions and a diagnosis of embolic myocardial infarction was made. Considering a good resolution of infection, and being the patient stable and asymptomatic, she was discharged after 6 weeks of antibiotic therapy for follow up in cardiology and neurosurgery consultations.

Discussion and conclusion

Despite appropriate antimicrobial treatment, embolic complications are common and usually develop during initial stage of IE. This case shows several embolic complications of IE, including embolic myocardial infarction and cerebral embolism. Although aggressive antibiotic administration was successful in this particular case and cardiac surgery was avoided, the identification of complications allowed a more strict follow up and was determinant for a good clinical result.

Abstract P1249 Figure.

The accuracy of PiCCO® in measuring cardiac output in patients under therapeutic hypothermia: Comparison with transthoracic echocardiography

BACKGROUND

Invasive cardiac monitoring using thermodilution methods such as PiCCO® is widely used in critically ill patients and provides a wide range of hemodynamic variables, including cardiac output (CO). However, in post-cardiac arrest patients subjected to therapeutic hypothermia, the low body temperature possibly could interfere with the technique. Transthoracic Doppler echocardiography (ECHO) has long proved its accuracy in estimating CO, and is not influenced by temperature changes.

OBJECTIVE

To assess the accuracy of PiCCO® in measuring CO in patients under therapeutic hypothermia, compared with ECHO.

DESIGN AND PATIENTS

Thirty paired COECHO/COPiCCO measurements were analyzed in 15 patients subjected to hypothermia after cardiac arrest. Eighteen paired measurements were obtained at under 36°C and 12 at ≥36°C. A value of 0.5l/min was considered the maximum accepted difference between the COECHO and COPiCCO values.

RESULTS

Under conditions of normothermia (≥36°C), the mean difference between COECHO and COPiCCO was 0.030 l/min, with limits of agreement (-0.22, 0.28) - all of the measurements differing by less than 0.5 l/min. In situations of hypothermia (<36°C), the mean difference in CO measurements was -0.426 l/min, with limits of agreement (-1.60, 0.75), and only 44% (8/18) of the paired measurements fell within the interval (-0.5, 0.5). The calculated temperature cut-off point maximizing specificity was 35.95°C: above this temperature, specificity was 100%, with a false-positive rate of 0%.

CONCLUSIONS

The results clearly show clinically relevant discordance between COECHO and COPiCCO at temperatures of <36°C, demonstrating the inaccuracy of PiCCO® for cardiac output measurements in hypothermic patients.

Acute bacterial meningitis in the intensive care unit and risk factors for adverse clinical outcomes: retrospective study

BACKGROUND

Bacterial meningitis constitutes a medical emergency. Its burden has driven from childhood to the elderly and the immunocompromised population. However, the admission of patients with bacterial meningitis to the intensive care unit (ICU) has been sparsely approached, as have the prognostic factors associated with an adverse clinical outcome.

METHODS

We performed a retrospective analysis during a 7-year period of patients older than 18 years admitted to 2 polyvalent ICUs. Clinical, demographic, and outcome data were collected to evaluate its clinical impact on the outcome of patients with acute bacterial meningitis.

RESULTS

We identified 65 patients with the diagnosis of acute bacterial meningitis (mean Acute Physiology and Chronic Health Evaluation II, 23; hospital mortality, 40%). Upon clinical presentation, their most frequent signs were fever (84%), seizures (21.5%), and a low Glasgow Coma Scale (GCS) score (GCS<8; 58.4%). Fifty-five patients (85%) required organ support. A definite microbiological diagnosis was achieved in 45 patients. An adverse clinical outcome was noted in 46 patients (71%). These patients were older (P=.005), had higher Physiology and Chronic Health Evaluation II score (P=.022), and had lower GCS (P=.022). In the multivariate analysis, older age (per year; adjusted odds ratio [aOR], 1.059) was associated with an adverse outcome, whereas a higher GCS (per point; aOR, 0.826) and presence of fever upon admission (aOR, 0.142) increase the chance of a good recovery.

CONCLUSIONS

Patients with acute bacterial meningitis admitted to ICU had substantial morbidity and mortality. Those with low GCS or absence of fever have a particularly high risk of an adverse outcome.

[Treatment of adolescent varicocele: is percutaneous embolization better?]

There are still doubts as to the most suitable criteria when considering surgery as the indication and optimal treatment for adolescent varicocele.

MATERIAL AND PATIENTS

We reviewed the hospital and primary health care histories of patients diagnosed by ultrasound for varicocele over the last 7 years. The data was taken from computerised clinical histories and hard copy back-up material stored and processed in computer format.

RESULTS

We studied 135 cases (mean age 12.8 years). These patients (125) were referred for scrotal swelling or as a result of chance detection, except for 10 patients who reported pain or scrotal asymmetry. Seventy-three underwent surgery and 62 continued as controls over the study period. The surgical indication was significant progressive asymmetry in testicular volume (28 children), high grade varicocele (41) as well as other reasons (4). We undertook percutaneous embolization in 44 patients (with a 66% relapse rate) and laparoscopic section of the spermatic cord with no arterial preservation in 29 (no relapses but 7 post-surgery hydroceles). No testicles were lost. At the end of the study 10 children continued as controls, 34 were discharged after recovery, 56 were referred to urology due to their age group, and 35 were lost to the study.

DISCUSSION

In the controversy over the treatment of varicocele our experience shows a high degree of relapses after embolization. Section of the spermatic vessels (including the artery) with no lymphatic preservation is highly effective but involves 27% post-op hydroceles, usually self-limiting (only one had later to undergo surgery), with no testicular atrophy or other complications.

CONCLUSIONS

We prefer complete laparoscopic section of the spermatic pedicle to embolization but it would be advisable to introduce modifications to avoid post-surgical hydrocele. Embolization must be reserved for patients with one testicle or with bilateral disease. Efforts must be made to communicate more effectively, in order to reduce the high drop-out rate.

[The vacuum chest wall lifter in the treatment of pectus excavatum]

Since 2002, the Eckart Klobe vacuum has been used in our Service as an innovate and non-invasive procedure in patients with pectus excavatum. This vacuum method contributes not only to hold promise as a valuable adjunct in minimally invasive surgery, but also as an effective method to lift and fix the funnel for repairing pectus excavatum in some patients. Our experience is limited to the use of this device in 10 patients, during the Nuss technique. This procedure has been useful for safer passage of the introducer, and as a definitive treatment in a 10 years old girl with pectus excavatum and a Haller index of 5.1 with successful result after one year of treatment. The aim of this study is to report the safety and efficacy of this procedure in appropriate patients. Long-term results will be necessary to confirm this method as an alternative to more invasive techniques.

Prevalence and associations of an abnormal ankle-brachial index in systemic lupus erythematosus: a pilot study

BACKGROUND

Accelerated atheroma is a well recognised complication of systemic lupus erythematosus (SLE). Its aetiology is multifactorial and several methods may be used to detect early signs of atheroma.

METHODS

Patients aged </=55 years were screened using the ankle-brachial index (ABI). Ninety one patients aged </=55 years and fulfilling the revised American College of Rheumatology criteria for SLE were studied. The ABI was measured using a contour wrapped 12 cm cuff attached to a mercury sphygmomanometer and an 8 MHz Doppler probe in the arms and legs; a ratio of <1 was considered abnormal.

RESULTS

The mean (SD) age of the patients was 39.0 (9.2) years. Of the 91 patients studied, 34 (37%) had an abnormal ABI. Only one patient was mildly symptomatic. Abnormal ABI correlated with age but not with disease duration, cumulative steroid dosage, ECLAM score, or any other traditional risk factors for atherosclerosis. In comparison with population studies, the prevalence of an ABI<1 in the patients with SLE with a mean age of 39 years was similar to that in adults aged over 80.

CONCLUSION

In this pilot study, patients with SLE with a mean age of 39 years had a high prevalence of an abnormal ABI. The ABI is a simple non-invasive tool for the early detection of accelerated atheroma in SLE.

Anti-dsDNA, anti-Sm antibodies, and the lupus anticoagulant: significant factors associated with lupus nephritis

BACKGROUND

Lupus nephritis (LN) is a common manifestation in patients with systemic lupus erythematosus (SLE). Autoantibodies and ethnicity have been associated with LN, but the results are controversial.

OBJECTIVE

To study the immunological and demographic factors associated with the development of LN.

PATIENTS AND METHODS

A retrospective case-control study of 127 patients with biopsy-proven LN, and 206 randomly selected patients with SLE without nephritis as controls was designed. All patients had attended our lupus unit during the past 12 years. Standard methods were used for laboratory testing.

RESULTS

Patients with LN were significantly younger than the controls at the time of SLE diagnosis (mean (SD) 25.6 (8.8) years v 33.7 (12.5) years; p<0.0001). The proportion of patients of black ethnic origin was significantly higher in the group with nephritis (p=0.02). There were no differences in sex distribution or duration of follow up. A higher proportion of anti-dsDNA, anti-RNP, anti-Sm, and lupus anticoagulant (LA) was seen in the group with nephritis (p=0.002; p=0.005; p=0.0001; p=0.01, respectively). In univariate, but not in multivariate, analysis male sex and absence of anti-dsDNA were associated with earlier onset of renal disease (p=0.03; p=0.008). In multivariate analysis the only factors associated with nephritis were younger age at diagnosis of SLE, black race, presence of anti-dsDNA, anti-Sm, and LA. No demographic or immunological associations were seen with WHO histological classes.

CONCLUSIONS

Young, black patients with anti-dsDNA, anti-Sm antibodies, and positive LA, appear to have a higher risk of renal involvement. These patients should be carefully monitored for the development of LN.

[Early surgery in Poland syndrome]

Poland's congenital malformation presents a variable grade of complexity, depending upon the extent of the muscular and chondro-costal defect. Surgical repair for cosmetic reasons only, may be performed during childhood or puberty due to the absence of symptoms. However, this does not occur when the costal defects has a considerable size, with pulmonary herniation and impairment of respiratory function. In this cases, early surgical correction is preferred in order to adequately stabilize the chest wall. In this paper we present our experience of early surgical treatment in 5 patients affected by a complex syndrome, that were treated with autologous costal transplants and the use pof polytetrafluoroethylene to cover the chest wall defect. We discuss the surgical procedure performed, as well as the advantages of this material with respect to others described up to date and the good results obtained in one of the cases followed-up for five years.

Leptogenesis via collisions: leaking lepton number to the hidden sector

We propose a leptobaryogenesis mechanism in which the nonzero B-L of the Universe is produced in out-of-equilibrium, lepton number and CP-violating scattering processes that convert ordinary particles into particles of some hidden sector. In particular, we consider the processes l phi-->l(')phi('),l macro(')phi(') mediated by the heavy Majorana neutrinos N of the seesaw mechanism, where l and phi are ordinary lepton and Higgs doublets and l('), phi(') are their hidden counterparts. Such a leptogenesis mechanism is effective even if the reheat temperature is much smaller than the heavy neutrino masses. In particular, it can be as low as 10(9) GeV.

[Non-infectious thrombotic endocarditis: a case report]

A 48 year-old female patient, admitted with an ischemic stroke, had a transesophageal echocardiogram (TEE) that revealed a dense vegetation in the noncoronary aortic cusp, which was considered the probable source of embolism. The clinical investigation did not identify any other disease or infectious process. However the lack of histologic proof, the absence of fever, the fact that the blood cultures were persistently negative, the patient recovery with no need of antibiotics, and the results of the TEE, are highly suggestive of the presence of a non infectious thrombotic endocarditis. After 18 months of anti-platelet treatment, the patient showed no new embolic episodes and TEE demonstrated the resolution of the vegetation.

[Complex anomalies of the anterior chest wall. Personalized surgical treatment]

Among the congenital anomalies of the anterior chest wall, the group of the asymmetrical deformities, mixed or complex, are the least frequent and the ones that require a difference surgical strategy for each patient according to their anatomical features. In this paper we present our experience and findings with this type of malformation. The fundamental aspects of the surgical indications and procedure are commented. The evolution and the results are very satisfactory. We stress the positive reaction of the patients and their families after the operation.

Cardiac hydatid cyst in a child

Cardiac hydatid cyst is a rare disease, especially in children. An 11-year-old boy with a previous anaphylactic reaction and episodes of abdominal pain was admitted for workup of an acquired long systolic murmur. Echocardiographic investigation disclosed a tumor of the right ventricular anterior wall, with multiple loculations. Magnetic resonance imaging characterized it as a multilobular tumor with cyst formation and disclosed another cyst in the right pulmonary artery. With a positive ELISA reaction the child was admitted for surgery with the diagnosis of cardiac and pulmonary hydatid cysts. Cardiac surgery was performed with good results, followed by medical treatment with albendazole.

[Malformations of the anterior thoracic wall]

The different anomalies of the anterior Chest Wall are exposed. We emphasize the deformities of the sternum--Depression and Protusion Deformities--because they are the most common and the most difficult ones to treat. Based in the results of 73 patients operated upon by the author, and in the review of the bibliography, we also comment on some aspects of the surgical indication, assessment methods, surgical technique, complications and results.

[Boix Ochoa's antireflux procedure returns patients to normalcy: 24 hour esophageal pH monitoring of 21 cases]

A great controversy exist concerning the surgical management of gastroesophageal reflux (GER). It is well known that Nissen procedure produces a hypercorrection of the gastroesophageal competency and often a "gas bloat syndrome". On the other hand, the Boix Ochoa's technique is more physiological but corrects GER allowing the persistence of a "radiological" reflux. The aim of the study was to demonstrate the accuracy of this procedure. 287 pediatric patients were studied because of GER and abnormal barium upper gastrointestinal series. 24 hours esophageal pH monitoring was performed in all this patients and in 21 the results were clearly pathological. They were operated on and six months later were new evaluated with upper GI series and continuous 24 hours esophageal pH monitoring. The results were compared with those previous to operation and also with a control group. Statistical great significance was found between presurgical and postsurgical data, what determine the efficacy of the procedure. No statistical significance was found between postsurgical data and the control group, what means that Boix Ochoa's procedure resolve GER without hipercorrection.

Branchio-oto-renal syndrome: incidence in three generations of a family

It is well known that the persistence of alterations in the normal embryological development of branchial arches can lead to preauricular and cervical fistulas within a family. However, until 1970, there were no reports of dysplasia affecting the branchial, otic, and renal systems (BOR syndrome) with dominant autosomic inheritance. The authors report on a family with BOR syndrome of different expressivity in three generations, and describe an unusual case of bilateral fistulas of the first and second branchial arches in a newborn.

[Persistent ductus arteriosus in the adult--report of a case]

The authors describe a case of congenital heart disease no longer frequent in adults, due to an early diagnosis and surgical treatment. The patent ductus arteriosus in adults who received no therapy can present several forms of evolution, depending on its own hemodynamic profile. The present case is an example of a congenital heart disease not diagnosed during the childhood, that developed pulmonary hypertension and congestive heart failure. These clinical situations have a bad prognosis and place this patient in a group of high surgical risk. Thus, surgery is not advisable considering the bad prognosis and early high mortality rate.

[Mesothelial cysts of the peritoneum in children]

The authors emphasize the existence of these cystic formations on the peritoneal surface. They point out that the exact diagnosis of the mesothelial cyst and the diagnostic workup with the cystic lymphangioma can only be done with an exhaustive histological examination.

[Study of the esophageal function by prolonged intraluminal pH-metry in patients with gastroesophageal reflux and respiratory manifestations]

Gastroesophageal reflux (GER) can be found in a high number of patients with respiratory tract disease (RTD). In the present study a 24 hours esophageal pH monitoring was performed in 55 children. 15 of them were normal controls, 16 patients with GER but normal score, 14 patients with GER and RTD and 9 patients with GER and only digestive symptoms. The number of reflux episodes of more than 5 minutes, the duration of the longest single reflux episode, the percentage of time the esophageal pH was less than 4, the reflux/hour index and the clearance index were measured. Comparing the results of the different groups we found that normal controls and normal vomiting patients were significatively different. Refluxers and refluxers with RTD also were different of asymptomatic controls. The main significative differences founded comparing refluxers and refluxers with RTD were the duration of the longest single reflux, the percentage of time the esophageal pH was less than 4 and the clearance index. All these parameters were longer in the refluxers with RTD. Our conclusion is that esophageal clearance is slower in the group of refluxers with RTD and that this index is helpful to distinguish them from the single refluxers.

[Testicular torsion: review of 42 cases]

Forty two cases of Testicular Torsion in children aged under 9 are presented. Diagnosis and therapy are discussed; an accurate and prompt diagnosis is emphasized on to decide on the proper surgical correction to achieve testes preservation.

[Idiopathic varicocele in children]

The authors present their experience with ten children operated on for left-sided idiopathic varicocele over a period of seven years. The treatment was high ligature of the spermatic vein with a favorable outcome in all cases. The histology of the testes, seen in biopsy, demonstrated a variable degree of damage. For this reason the authors recommend that this operation should be done in childhood in order to avoid problems of subfertility or infertility in adult life.

[Primary segmental infarction of the omentum in children (author's transl)]

Authors describe characteristics of this rare disease, as cause of acute abdomen in infancy. They base this on the study of two cases. They establish criteria for differential diagnosis of acute appendicitis, as well as surgical treatment and pathological conditions found during surgery.

[Sympathetic participation in the control of thyroid function (author's transl)]

A sympathectomy of the left thyroid lobe was carried out in 17 guinea pigs by sectioning the inferior thyroid artery. Thirty days after the surgical procedure, the animals were killed and the thyroids, together with the trachea and esophagus, were collected for histological processing. Histological, caryometric, and folliculometric studies revealed that the nuclei and thyroid follicles of the operated lobe were significantly larger than in the control lobe. Five guinea pigs were subjected to a temperature of 2 degrees C for 10 hours prior to killing; the thyroid lobe of the control showed a significant increase in the size of the nuclei and follicles. The operated lobe, on the other hand, showed no change. These results favour the hypothesis that sympathetic innervation plays an important role in the normal functioning of the thyroid as well as in a stress situation caused by cold.

[Mesenterial lipoma in a child (author's transl)]

A rare case of a 16-month old infant with a mesenteric lipoma is presented. Symptomatology, diagnosis and surgical approach are discussed. Authors make a review of previously reported cases in the infant age.