Reexpansion pulmonary edema occurring after thoracoscopic drainage of a pleural effusion

Video assisted thoracoscopic drainage and tale pleurodesis was used to treat a recurrent pleural effusion in a 60 year-old woman undergoing major gynecologic surgery. She developed reexpansion pulmonary edema immediately following surgery. Several important risk factors that were present in this patient are discussed. In addition to almost, complete collapse of the underlying lung for several weeks, thoracoscopy resulted in manipulations and rapid re-inflation of the underlying lung, which further increased the risk to the patient.     

A case with subcapsular hematoma of the liver following laparoscopic cholecystectomy

The occurrence of intracerebral hemorrhage during an acute attack of migraine remains questionable. A normotensive migrainous woman experienced multiple intracerebral hemorrhages. No drug abuse was recorded, but bleeding occurred after the use of several antimigrainous drugs. Angiography revealed severe vasospasm of both anterior cerebral arteries. Subsequent brain MRI and MRI angiography failed to show any vascular abnormalities. Echocardiography and an exhaustive biological evaluation ruled out an alternative condition favoring intracerebral hemorrhage. Multiple intracerebral hemorrhages in migraine may exceptionally be related to vasospasm leading to arterial wall injury. Intracranial arterial vasospasm could be precipitated by excessive vasoactive therapy.     

Hydrocephalus requiring urgent external ventricular drainage in a patient with diabetic ketoacidosis and cerebral edema: case report

OBJECTIVE AND IMPORTANCE: Neurological deterioration, typically attributed to cerebral edema, is a rare but life-threatening complication in the treatment of diabetic ketoacidosis (DKA). We report the case of a child with DKA who became comatose but demonstrated acute obstructive hydrocephalus, instead of cerebral edema. CLINICAL PRESENTATION: An 11-year-old male patient presented with new-onset insulin-dependent diabetes mellitus and DKA. He was initially responsive but, after several hours of treatment, became unresponsive, with dilated pupils and decerebrate posturing. Cranial computed tomographic scanning demonstrated obstructive hydrocephalus resulting from focal cerebellar and brain stem edema. INTERVENTION: The patient was initially managed with medical treatment but ultimately required urgent ventricular drainage to arrest a progressive herniation syndrome. To our knowledge, this report describes only the second such case reported and the first requiring urgent ventriculostomy. CONCLUSIONS: These observations emphasize the importance of recognizing hydrocephalus as a potentially reversible cause of coma in DKA and of initiating prompt neurosurgical intervention, if warranted.     

High-altitude pulmonary edema: a clinical crisis

High-altitude pulmonary edema is a serious clinical condition observed in individuals participating in mountain climbing and skiing at high altitudes. High-altitude pulmonary edema is an oncardiogenic form of pulmonary edema. Atrial natriuretic factor and endothelin are implicated and ventilatory support is important in preventing fatalities.     

High-altitude pulmonary edema at a ski resort

MRI can accurately define the extension of cervical carcinoma to the parametria. However, in patients with cervical carcinoma clinical stage IB, the definition of the dimensions of the tumour, prior to surgery, and may also modify the treatment procedure. Recently pre-operative neoadjuvant chemotherapy has been proposed for patients with bulky tumours. Multiple factors may influence the prognosis of clinical stage IB and survival varies greatly among these patients. In particular the maximum dimensions of the tumour seem to have a prognostic relevance. The aim of this paper is to evaluate the potential of MRI to measure tumour size, in order to discriminate between patients needing surgery alone or pre-operative therapy followed by surgery. In 20 patients with clinical stage IB cervical carcinoma we performed MRI to measure the radius of the cervix, the radius of the tumour and their ratios. The measurements obtained have been compared with the corresponding data from histopathology of the operative specimens. The close correspondence between these linear measurements allows us to propose MRI as a reliable method to define tumour size in clinical stage IB patients before surgery.     

A case of acute pulmonary edema and bulbar paralysis after local epinephrine infiltration

A cataract developed in a 23-year-old man 4 months after a vitrectomy to repair a traumatic retinal detachment. An uneventful phacoemulsification was performed, using antibiotic-fortified infusion solution. Afterward, a large area of atrophic retina, consistent with gentamicin toxicity, was observed in the macula. The patient remains stable with 20/200 best-corrected acuity. The authors suggest that because the vitreous had been removed, gentamicin was able to settle over the macula during the entire cataract procedure. Therefore, gentamicin should be used intracamerally with caution, especially in eyes in which vitrectomy has been performed.     

Multivariate changes in coordination of postural control following spaceflight

BACKGROUND: Bright light therapy is the recommended treatment for winter seasonal affective disorder (SAD). However, the studies with the best placebo controls have not been able to demonstrate that light treatment has a benefit beyond its placebo effect. METHODS: Ninety-six patients with SAD completed the study. Patients were randomly assigned to 1 of 3 treatments for 4 weeks, each 1.5 hours per day: morning light (average start time about 6 AM), evening light (average start about 9 PM), or morning placebo (average start about 6 AM). The bright light (approximately 6000 lux) was produced by light boxes, and the placebos were sham negative-ion generators. Depression ratings using the Structured Interview Guide for the Hamilton Depression Rating Scale, SAD version (SIGH-SAD) were performed weekly. RESULTS: There were no differences among the 3 groups in expectation ratings or mean depression scores after 4 weeks of treatment. However, strict response criteria revealed statistically significant differences; after 3 weeks of treatment morning light produced more of the complete or almost complete remissions than placebo. By 1 criterion (24-item SIGH-SAD score <50% of baseline and < or =8), 61% of the patients responded to morning light, 50% to evening light, and 32% to placebo after 4 weeks of treatment. CONCLUSIONS: Bright light therapy had a specific antidepressant effect beyond its placebo effect, but it took at least 3 weeks for a significant effect to develop. The benefit of light over placebo was in producing more of the full remissions.     

Arterial blood gases in acute pulmonary edema

Arterial blood gas and pH measurements in 82 patients with acute pulmonary edema of cardiogenic origin entering the emergency department varied widely and were unpredictable using clinical examination. The mean arterial oxygen tension (PaO2) measured in 71 patients breathing room air was 59 mm Hg. Fourteen of the 82 patients were acidemic; 35, alkalemic and 33 had a pH in the normal range. The acidemic group had markedly lower PaO2, all under 60 mm Hg. Oxygen and furosemide were used in all cases and effectively corrected the hypoxia and reduced pulmonary congestion. Other drugs used included aminophylline (14 patients), morphine sulfate (9 patients) and digoxin (3 patients). Five of the nine patients who received morphine were hypercarbic initially but the CO2 retention did not worsen. No patient died during the initial 48 hours. This study reiterates the importance of directing therapy at ventilatory and cardiac abnormalities and points out the value of arterial blood gas monitoring to assess the initial status, monitor the patient's course, and to select drug therapy.     

Postoperative acute pulmonary edema: a rare presentation of pheochromocytoma

The Duromedics bileaflet pyrolitic carbon mechanical prosthesis was introduced by Hemex in 1982 and subsequently acquired by Baxter. This communication documents a case of sudden leaflet fracture of a Duromedics mitral valve 48 months after implantation, which was managed successfully by replacement with a St. Jude Medical mechanical prosthesis. The patient presented in acute distress with paroxysmal atrial tachycardia and pulmonary edema. Transesophageal echocardiography was used to diagnose the leaflet fracture. The fracture had occurred transversely, with the fragments embolizing bilaterally to the iliofemoral arteries. These were removed at a subsequent operation. Cases of such fractures of the Duromedics prosthesis have been reported, with cavitation damage being the postulated mechanism.     

Drug-induced pulmonary edema in a patient infected with human immunodeficiency virus

Adverse reactions to drugs are common in patients infected with the human immunodeficiency virus (HIV). In these patients pulmonary reactions to drugs may be difficult to differentiate from opportunistic pulmonary infections. We report a HIV-infected patient who on two occasions developed acute pulmonary edema related to the administration of ibuprofen.     

Sever acute pulmonary edema after peri-anesthetic laryngospasm in a newborn infant

Severe acute pulmonary oedema following peranaesthetic laryngospasm in a newborn. The authors report a case of severe acute pulmonary oedema secondary to a laryngeal spasm in a 3-week-old neonate, immediately after induction of anaesthesia with halothane. After emergency tracheal intubation, the infant experienced a severe, life-threatening pulmonary oedema requiring prolonged intensive care. Such a secondary time course is unusual. Usually pulmonary oedema has a favourable outcome after oxygen administration and maintenance of positive expiration pressure, except in the neonate.     

Role of nitric oxide in sepsis-associated pulmonary edema

Transient pulmonary hypertension after inhibition of nitric oxide synthase (NOS) does not alter pulmonary reflection coefficients or lymph flows in endotoxemic sheep. To test the effects of persistent pulmonary hypertension induced by N omega-nitro-L-arginine methylester (L-NAME) and of inhaled NO on pulmonary edema, 18 sheep (three groups) were chronically instrumented with pulmonary artery catheters, femoral arterial fiberoptic thermistor catheters, and tracheostomy. The awake, spontaneously breathing animals received Salmonella typhi endotoxin (lipopolysaccharide; LPS) (10 ng/kg/ min) for 28 h. After 24 h, an airflow of 6 L/min was delivered through the tracheostomy. One group of animals (L-NAME/air) received L-NAME intravenously (25 mg/kg + 5 mg/kg/h) and breathed air. The second group (L-NAME/NO) was given L-NAME and NO (40 ppm) was added to the airflow. The third group was given NaCl 0.9% and breathed air (NaCl/air). Extravascular lung water was measured through the double-indicator dilution technique. Endotoxemia caused pulmonary edema, which was aggravated by L-NAME. Breathing of NO normalized pulmonary artery pressure (Ppa) and ameliorated pulmonary edema. Inhalation of NO may therefore be a therapeutic option for pulmonary edema associated with pulmonary hypertension.     

Unsuspected carcinoma of the gall bladder: case report of trocar-site metastasis following laparoscopic cholecystectomy

Cancer of the gall bladder is a rare malignant neoplasm with an unfavourable prognosis. Laparoscopic surgery has brought about the emergence of possible neoplastic diffusion along trocar tracts in cases where unrecognized carcinoma of the gall bladder is present. The authors present a case of neoplastic abdominal diffusion discovered 4 months after laparoscopic cholecystectomy in which histologic examination of the surgical specimen revealed the presence of unrecognized carcinoma of the gall bladder.     

Standard means in laparoscopic surgery. The peculiar case of cholecystectomy

Legal suits against visceral surgeons have increased since the advent of laparoscopic surgery. The duties of physicians have not however changed with the development of laparoscopic techniques. Since the decree promulgated in 1936, physicians have a legal commitment to provide the means required for patient care. This obligation has been recalled in different court judgements and in the new deontology code. In addition, jurisprudence tends more and more towards responsibility without risk. Laparoscopic cholecystectomy is not risk-free. Although morbidity and mortality have not risen with laparoscopic procedures, the types of complications encountered have changed. Reported accidents have become more frequent. The number of suits against surgeons has also increased. Surgeons must therefore be highly prudent and diligent. Precautions concerning personnel management, the choice of material and its upkeep. Special care must be given to the peroperative pneumoperitoneum and the use of monopolar electrocoagulation. A peroperative cholangiogram should be obtained. A careful operative report is very important. The surgeon must be able to justify his competence. Finally, the surgical community should publish more results concerning the rate of complications in order to establish reference material for experts.     

Tree-shaped pulmonary veins in infracardiac total anomalous pulmonary venous drainage

Three consecutive patients undergoing corrective operation for the infracardiac type of total anomalous pulmonary venous drainage (TAPVD) were found to have tree-shaped pulmonary veins. Preoperative angiocardiography revealed that in 2 patients the superior and inferior pulmonary veins drained separately, bilaterally, into the vertical vein. In the third patient the right pulmonary veins united to connect with the vertical vein, while the left superior and inferior pulmonary veins drained separately into the vertical vein. At operation inferior pulmonary veins connecting separately with the vertical vein were found to be located posterior to the pericardium. In the previous literature dealing with successful repair of infracardiac TAPVD, there is no mention of the tree-shaped pulmonary veins described in this report. As this particular type of pulmonary vein does not seem to be uncommon, its possible presence should be kept in mind during operation, as it may dictate the selection of surgical procedures.     

The standards of care in laparoscopic surgery. The specific case of cholecystectomy

Legal suits against visceral surgeons have increased since the advent of laparoscopic surgery. The duties of physicians have not however changed with the development of laparoscopic techniques. Since the decree promulgated in 1936, physicians have a legal commitment to provide the means required for patient care. This obligation has been recalled in different court judgements and in the new deontology code. In addition, jurisprudence tends more and more towards responsibility without risk. Laparoscopic cholecystectomy is not risk-free. Although morbidity and mortality have not risen with laparoscopic procedures, the types of complications encountered have changed. Reported accidents have become more frequent. The number of suits against surgeons has also increased. Surgeons must therefore be highly prudent and diligent. Precautions concerning personnel management, the choice of material and its upkeep. Special care must be given to the peroperative pneumoperitoneum and the use of monopolar electrocoagulation. A peroperative cholangiogram should be obtained. A careful operative report is very important. The surgeon must be able to justify his competence. Finally, the surgical community should publish more results concerning the rate of complications in order to establish reference material for experts.