Fatal postoperative tension pneumocephalus after acute subdural hematoma evacuation: a case report

PURPOSE

Tension pneumocephalus (TP) represents a rare pathology characterized by constant accumulation of air in the intracranial space, being associated with increased risk of herniation, neurologic deterioration and death. Regarding neurosurgical trauma cases, TP is majorly encountered after chronic subdural hematoma evacuation. In this case report, we present a rare case of fatal postoperative TP encountered after craniotomy for evacuation of acute subdural hematoma (aSDH).

CASE PRESENTATION

An 83-year old gentleman was presented to the emergency department of our hospital with impaired level of consciousness. Initial examination revealed Glascow Coma Scale (GCS) 3/15, with pupils of 3 mm bilaterally and impaired pupillary light reflex. CT scan demonstrated a large left aSDH, with significant pressure phenomena and midline shift. Patient was subjected to an uneventful evacuation of hematoma via craniotomy and a closed subgaleal drain to gravity was placed. The following day and immediately after his transfer to the CT scanner, he presented with rapid neurologic deterioration with acute onset anisocoria and finally mydriasis with fixed and dilated pupils. Postoperative CT scan showed massive TP, and the patient was transferred to the operating room for urgent left decompressive craniectomy, with no intraoperative signs of entrapped air intracranially. Finally, he remained in severe clinical status, passing away on the eighth postoperative day.

CONCLUSION

TP represents a rare but severe neurosurgical emergency that may be also encountered after craniotomy in the acute trauma setting. Involved practitioners should be aware of this potentially fatal complication, so that early detection and proper management are conducted.

Perioperative Antibiotic Prophylaxis: An Educative Intervention Significantly Increases Compliance

BACKGROUND

Implementation of guidelines in daily clinical practice is often suboptimal, mainly due to doctors' poor compliance with them. Perioperative antibiotic prophylaxis (PAP) is many times administered in patients undergoing elective surgery without proper indication or for longer time than needed. Aim of this study is to investigate the effect of a simple intervention on the compliance of the medical staff with the American Society of Health-System Pharmacists (ASHP) guidelines concerning PAP administration.

METHODS

A prospective 3-month audit took place including routine surgical procedures (laparoscopic cholecystectomy, inguinal hernia repair and thyroidectomy). An intervention aiming to educate the medical staff was implemented. The intervention included the demonstration of a poster and the training of the medical staff over the guidelines. A re-audit recorded the changes in daily clinical practice.

RESULTS

The compliance rate regarding the number of PAP doses significantly increased from 0% before the intervention to 68.8% after the intervention for hernia repair and to 53.1% for laparoscopic cholecystectomy. The adherence rate in thyroidectomies increased from 25% to 50%, but without statistical significance. No significant difference was found for other parameters of PAP administration, namely the type of antibiotic used and the timing of the dose administration. Regarding secondary outcomes, hospitalization days were reduced, and cost of antibiotics was significantly decreased (P < 0.05).

CONCLUSIONS

A simple intervention intending to educate the medical staff was successful in achieving significant improvement on the compliance rate with the PAP guidelines, highlighting the importance of promoting adherence to the already existing, well-established guidelines.