Arzu Gercek

Percutaneous endoscopic gastrostomy in the neurosurgical intensive care unit: complications and outcome.

BACKGROUND Even with a functioning gastrointestinal tract, it is not always easy to initiate oral feeding in some neurosurgical patients because of their persistently depressed neurologic status or severe lower cranial nerve palsies. Percutaneous endoscopic gastrostomy (PEG) may be required for long-term feeding in these patients. The purpose of the present study is to report our experience with PEG chosen for establishing an enteral route in patients of neurosurgical intensive care unit (ICU). METHODS The outcome and complications of PEG in neurosurgical ICU patients of Marmara University Institute of Neurological Science between January 2001 and November 2006 were retrospectively evaluated. RESULTS Thirty-one patients, with the median age of 51 years (range, 14-78 years) underwent PEG placement. PEG was placed before the craniotomy in 2 patients and after in 29. Indications for PEG were absent gag reflex in 10 patients and low Glasgow Coma Scale score in 21. Before the PEG tube insertion, 18 patients had enteral nutrition by a nasogastric tube and 10 had parenteral nutrition (PN), with a median duration of 14.5 (range, 4-60) and 12 (range, 7-25) days, respectively. Two patients accidentally pulled out the gastrostomy tubes 10 and 11 days after insertion. Buried bumper syndrome developed in 1 patient. Two patients died 8 and 34 days after the procedure in the neurosurgical ICU. Twenty-nine patients were discharged from the hospital while being fed via the PEG tubes. In 11 patients who were able to resume oral feeding, the tube was removed, with a median interval of 62 (range, 25-150) days. Procedure-related mortality, 30-day mortality, and overall mortality of the patients were 0%, 6.4%, and 45%, respectively. CONCLUSION PEG is a safe and well-tolerated gastrostomy method for neurosurgical ICU patients with depressed neurologic state or severe lower cranial nerve palsies.

The effects of inflammatory response associated with traumatic spinal cord injury in cutaneous wound healing and on expression of transforming growth factor-beta1 (TGF-β1) and platelet-derived growth factor (PDGF)-A at the wound site in rats

At the cellular level, spinal cord injury (SCI) provokes an inflammatory response that generates substantial secondary damage within the cord, but also may contribute to its repair. The aim of this study was to investigate the effects of inflammatory response associated with SCI in cutaneous wound healing and on expression of transforming growth factor-beta1 (TGF-β1) and platelet-derived growth factor (PDGF)-A at the wound site in rats. At the 14th day analysis, the mean TGF-β1 score in trauma group (I) was significantly lower than that in control group (C) (2.60 ± 0.90 vs. 3.64 ± 0.37, respectively; p < 0.05). The mean score for PDGF-A expression in group I was similar to the corresponding value in group C (2.42 ± 0.74 vs. 2.94 ± 0.72, respectively). Compared to group C, group I had significantly lower mean scores for epidermal and dermal regeneration, but higher mean scores for granulation tissue thickness and similar scores for angiogenesis. The dermal layer contains diffuse deposition of collagen fibers that are not organised as in control rat skin, and intraepidermal and subepidermal vasocongestion is distinct. Based on the results on the parameters evaluated in the study, experimental SCI in rats results in delay in wound healing and low intensity of TGF-β1 in the dorsal wound-tissue specimens.

Effects of parenteral fish-oil emulsion (Omegaven) on cutaneous wound healing in rats treated with dexamethasone

BACKGROUND The aim was to assess wound healing when parenteral fish-oil emulsion is given to rats receiving dexamethasone. METHODS For 5 days after skin wounding, group S (control; n = 7) received saline 1 mL/kg intraperitoneal (IP); group D (n = 7), dexamethasone 0.2 mg/kg IP; and group DO (n = 9), dexamethasone 0.2 mg/kg IP plus 1 mL/kg Omegaven (Fresenius Kabi, Austria). Wound specimens were assessed for hydroxyproline level, wound depth, histology (epidermal/dermal regeneration, granulation tissue thickness, and angiogenesis), and expression of transforming growth factor-beta (TGF-beta) and platelet-derived growth factor-AA (PDGF-AA). RESULTS Compared with D and DO specimens, controls had higher hydroxyproline (p < .01), deeper wounds (p < .05), and better histologic scores (p < .01 angiogenesis; others p < .05). There were no significant differences between the group D and DO means for hydroxyproline level, wound depth, or histologic scores (p > .05 for all). Controls had higher TGF-beta expression scores than the other groups (p < .01 for both) and a higher PDGF-AA expression score than group DO (p < .01). Groups D and DO had statistically similar TGF-beta scores, but group D had a higher PDGF-AA score (2.71 +/- 0.75 vs 1.55 +/- 0.72, respectively; p < .05). CONCLUSIONS According to the parameters we studied, adding parenteral omega-3 and omega-6 fatty acids to the nutrition regimen of rats treated with dexamethasone does not seem to have adverse effects on wound healing, and effects on wound healing may not need to be considered when determining if these agents should be supplemented in nutrition support regimens.

Microvessel density and vascular endothelial growth factor expression as predictors of childrens' survival from cerebellar medulloblastoma.

Cerebellar medulloblastoma is the most common malignant brain tumor of childhood. This neoplasm is highly vascular and has a high growth rate. We aimed to determine whether high microvessel density (MVD) and expression of vascular endothelial growth factor (VEGF) in medulloblastoma tissue is correlated with survival time in children with this tumor. Tissue from 32 cerebellar medulloblastomas in 14 girls and 18 boys was studied. The standard-risk group comprised patients older than 3 years, without metastases of medulloblastoma and a residual post-operative tumor with a surface area less than 1.5 cm(2). The patients assigned to a high-risk group had at least one of the following indicators: younger than 3 years, metastases, or a residual post-operative tumor with a surface area larger than 1.5 cm(2). For each tumor, MVD was determined and the expression of VEGF was assessed using immunohistochemical techniques. The 5-year survival rate for the 32 patients was 56.2%. Five-year survival rates were 70.6% and 40.0% for patients in the standard-risk and high-risk groups, respectively. The mean (+/-standard deviation, SD) MVD for all patients was 22.0+/-9.1 microvessels per 0.7 mm(2). There was no difference in the survival rate between the groups with above-average MVD and below-average MVD (66.7% and 50.0%, respectively). Testing revealed 7 tumors with VEGF expression and 25 without. The 5-year survival rates for these 2 groups were not significantly different (57.1% vs. 56.0%, respectively). The mean (+/-SD) MVD values for the VEGF-positive and VEGF-negative groups were not significantly different (19.1+/-6.5 vs. 22.9+/-9.7 microvessels per 0.7 mm(2), respectively, Mann-Whitney U-test=78.5, Z=-0.41, p=0.68). There were no significant correlations between risk groups and expression of VEGF or MVD. These results indicate that neither high MVD nor the expression of VEGF in tumor tissue predicts poor prognosis in children with cerebellar medulloblastoma.

Foot drop : The first sign of an intracranial tumor?

Isolated foot drop due to a brain lesion is rare. A 48-year-old man complained of inability to dorsiflex the right foot. Right dorsiflexion had 0/5 muscle strength and there were no upper neuron findings on his neurological examination. Magnetic resonance imaging of the brain revealed a left parasagittal brain mass. The lesion was removed and muscle activity returned with 3/5 muscle strength 6 weeks after the operation. The parasagittal area is located at the foot of the homunculus. Therefore, in patients with foot drop, lesions of the parasagittal area should be considered.

Tumoral calcinosis and epidural lipomatosis of the lumbar spine.

Lumbar spinal tumoral calcinosis and spinal epidural lipomatosis are rare conditions. We present a 70-year-old female patient with serology negative spondyloarthropathy who developed paresis due to tumoral calcinosis in the left facet joint between L5 and S1 levels and spinal epidural lipomatosis at L5 and S1 levels. Surgery was performed to excise the lesions en bloc. Neural decompression was provided. Neurological symptoms improved after surgery. Here, we report the first serology negative spondyloarthropathy case that had concomitant development of tumoral calcinosis and spinal epidural lipomatosis.

Spinal abscess after epidural anesthesia: need for more vigilance and better patient advice.

To JNA Readership: Development of a spinal epidural abscess after epidural catheterization is very rare, but it is the most serious late complication of this procedure. Anesthesiologists and surgeons should be aware of all the potential complications of this procedure and should warn patients about related signs and symptoms. In this letter we describe a patient in whom an epidural abscess was diagnosed 1 month after epidural anesthesia for total knee arthroplasty. A 77-year-old woman presented to our emergency clinic with severe lowback pain, urinary incontinence, and complete loss of sensation and complete loss of motor function of the left lower extremity. One month earlier she had undergone total left knee arthroplasty with epidural anesthesia. Apart from the knee problem, she had been in good health prior to presentation. Three weeks after the operation, she started to experience pain in her knee and lower back, which had gradually worsened in the week prior to presentation. The patient first noticed pins-and-needles sensation in the operated leg by postoperative day 30; this had progressed to complete loss of sensation and complete loss of motor function. Laboratory studies at admission revealed peripheral white blood cell count 13,200/mm, erythrocyte sedimentation rate 75 mm/h, and serum C-reactive protein 79 mg/dL. An ELISA test for human immunodeficiency virus was negative. Magnetic resonance imaging of the lumbar spine demonstrated a multilobular cystic mass that measured 18 × 16 × 78 mm and extended from T12 to L5. The lesion was heterogeneously hypointense on T1-weighted images (Figs. 1 and 2 left) and heterogeneously hyperintense on T2-weighted images (Figs. 1 and 2 right), and showed mild enhancement after intravenous injection of gadolinium. The differential diagnosis was epidural hematoma or abscess, and emergency surgery was carried out immediately. A midline posterior skin incision was made from T12 to S1, and laminectomies were performed at L1, L2, and L4. This exposed a massive epidural abscess that filled the entire surgical field. A sample of abscess material was collected for microbiological examination, and then antibiotic therapy was started with cefazolin sodium 1 g given intravenously. This treatment was continued three times daily postoperatively. The abscess was carefully drained, and the surgical field was irrigated with physiologic saline and hydrogen peroxide. A drain was placed in the epidural space and left in position for 48 hours postoperatively. Gram staining of a specimen of the drainage material revealed grampositive cocci. Methicillin-sensitive Staphylococcus aureus was subsequently isolated from cultures of the abscess material. The loss of motor function and sensation in the patient’s left leg resolved in the first week after surgery. After 3 weeks of parenteral antibiotics, she was discharged on a 4-week course of oral trimethoprim-sulfamethoxazole 1 g twice daily. A recheck in the eighth week after surgery revealed complete recovery, and there was no abscess recurrence during follow-up. Development of spinal epidural abscess after epidural anesthesia is one of the most serious complications of epidural anesthesia. The reported incidence rates range from 1 in 506,000 obstetric cases to 3% in cases requiring chronic pain management. Staphylococcal species are the most common causative organisms in spinal epidural abscess. Diabetes mellitus, chronic renal failure, immune incompetence, and alcoholism are frequent predisposing factors in patients with epidural abscess. Our patient had none of these risk factors, but epidural anesthesia itself is a risk factor for spinal epidural abscess. Strict attention to sterile technique is crucial when performing epidural catheterization. In research on 40 cases of spinal epidural abscess, Hlawin et al found that skin and soft-tissue injuries were the main routes of bacterial entry. The break in the skin is a potential site of entry for infectious microorganisms, and several methods for cleansing the FIGURE 1. MRI showing T1-weighted (left) and T2-weighted (right) sagittal images.

Anesthetic management of a newborn with Mohr (oro-facial-digital type II) syndrome.

1 Weiss M, Gerber AC. Cuffed tracheal tubes in children things have changed. Pediatr Anesth 2006; 16: 1005–1007. 2 Dillier CM, Trachsel D, Baulig W et al. Laryngeal damage due to an unexpectedly large and inappropriately designed cuffed pediatric tracheal tube in a 13-month-old child. Can J Anaesth 2004; 51: 259–263. 3 James I. Cuffed tubes in children. Paediatr Anaesth 2001; 11: 259– 263. 4 Holzki J. Laryngeal damage from tracheal intubation. Paediatr Anaesth 1997; 7: 435–437.

Prevention of brisk hyperactive response during selective dorsal rhizotomy in children with spasticity: isoflurane versus sevoflurane maintenance anesthesia.

In children with spasticity, deep tendon reflexes are hyperactive and even stimulation of normal dorsal rootlets can produce exaggerated full-strength, single-twitch responses in the muscles they innervate. This phenomenon is called the brisk hyperactive response (BHR). The aim of this study was to compare the efficacy of 2 volatile anesthetics, isoflurane and sevoflurane, for suppressing the confounding effect of BHR during selective dorsal rhizotomy (SDR) in children with spasticity. The subjects were 54 consecutive children of American Society of Anesthesiology physical status III who were scheduled for SDR. After tracheal intubation, each child was randomly assigned to Group I (isoflurane; n=27) or Group S (sevoflurane; n=27). There was no significant difference between the mean operation times in Groups I and S (200+/-40 vs. 220+/-35 minutes, respectively; p=0.0559). Thirteen patients in Group I (48.1%) and 5 in Group S (18.5%) exhibited BHR during stimulation of the dorsal rootlets (odds ratio 4.086; p=0.0418). Three of these 18 patients (2 in Group I and 1 in Group S) experienced hypertension and tachycardia simultaneously with BHR (odds ratio 4.086; p=1.0). The results suggest that sevoflurane is more effective at preventing BHR and might be a better choice for anesthetic management of children with spasticity undergoing SDR.

Co-existence of Pott's disease and alkaptonuria in a 21-month-old child.

reported in a case with PDA 30 h after the procedure (4). The migrated devices are usually removed surgically, whereas in the presented case the device was removed by endovascular techniques. Two patients had late complications: peripheral embolization in the left leg 1 year after implantation of an Amplatzer device and sudden death 1.5 year later (2). In such procedures, regardless of the occluder type, the migration of device can happen in 1.1% of the cases and surgical removal is required in 0.2% of all the cases (3). Early and easy migration of the device can be caused by the technical reasons like inappropriate choice of the device (insufficient length of the rim). Device-defect ratio also had a significant effect on delivery success and composite success. Defect stretch diameter had the largest influence on outcome, and implantation was possible in only 67% if the stretched diameter of the defect was >20 mm (5). The other possible causes of migration of the device are either because of choice of the occluder or less experience in application of the device. The migration of the device in percutaneous transcatheter occlusion procedures may cause life-threatening complications and we suggest that all patients should go to intensive care unit postoperatively. The anesthesiologists should be careful to the developing techniques and complications of such procedures. Yusuf Unal M D* Serdar Kula M D† Gokcen Emmez M D* Rana Olgunturk M D† Sahin Yardim M D* *Department of Anesthesiology and Reanimation and †Department of Pediatric Cardiology, Gazi University School of Medicine, Ankara, Turkey (email: yunal71@yahoo.com, yunal@gazi.edu.tr) References