Hiroshi Dohgomori

Application of normal saline to ultrasonography as an alternative to gel for internal jugular venous cannulation

CAN J ANESTH 54: 3 www.cja-jca.org March, 2007 Gastroenterol 2006; 101: 812–22. 2 Munoz P, Bouza E, Cuenca-Estrella M, et al. Saccharomyces cerevisiae fungemia: an emerging infectious disease. Clin Infect Dis 2005; 40: 1625– 34. 3 Enache-Angoulvant A, Hennequin C. Invasive Saccharomyces infection: a comprehensive review. Clin Infect Dis 2005; 41: 1559–68. 4 Lherm T, Monet C, Nougière B, et al. Seven cases of fungemia with Saccharomyces boulardii in critically ill patients. Intensive Care Med 2002; 28: 797–801. 5 Johnston BC, Supina AL, Vohra S. Probiotics for pediatric antibiotic-associated diarrhea: a meta-analysis of randomized placebo-controlled trials. CMAJ 2006; 175: 377–83.

Migration of foreign body from mouth to nose.

A man appeared in the Emergency Department complaining of discomfort in his neck because he had swallowed a tooth-pick while taking a nap. The examining physician could find no foreign body in the patient’s mouth or pharynx. An additional examination using a fiberscope disclosed the existence of a foreign body in the nose. The toothpick was thought to have migrated to the nose from the pharynx after it was swallowed. Foreign bodies of various sizes may migrate to the nose from other parts of the body. Therefore, protocols must be designed for additional examination of the nose.

Hyperbaric oxygen therapy (HBOT) in a child with suspected influenza-associated encephalopathy

To the Editor: A three-year-old girl felt feverish, and the next day became comatose with convulsions. A computed tomography scan revealed diffuse cerebral edema. Encephalopathy associated with influenza (EI) was suspected. On day two she was transferred to the intensive care unit where she underwent hypothermia therapy under artificial ventilation. On day eight, influenza-A-positive antigen was identified in her nasal discharge. She recovered from her critical state and was extubated. However, her consciousness remained disturbed with no signs of recovery over the next six days. In Japan, hypoxic encephalopathy is one of the indications for HBOT. She had status epilepticus, which might also be suggestive of brain hypoxia. With this in mind, we decided that HBOT was a treatment option. After obtaining informed consent from her parents, HBOT (one session per day) was started on day 14. After the second HBOT session, she made eye contact and said one word. Six HBOT sessions were performed in total, and the patient was discharged home on day 34 with no sign of brain dysfunction. No factor other than HBOT readily explained the dramatic recovery, a situation analogous to that described in a previous study.1 For some years, HBOT has been used for the treatment of coma due to post-anoxic encephalopathy,2 and the active use of HBOT for global cerebral ischemia and coma has also been stressed. However, the benefit of HBOT for coma associated with EI remains unclear. EI is a severe condition which can result in serious brain damage and cause rapid death within a few days. Mortality is as high as 26.7–43.8%3,4 and, even in survivors, the incidence of neurological sequelae is 20.3–25.8%.3,4 Although ways of preventing EI-induced death and sequelae are urgently needed, reliable methods do not yet exist. Using hypothermia against EI is a possible approach and its effectiveness is currently being evaluated in Japan. Actually, HBOT is not considered an appropriate indication for patients with closed head injury (CHI).5 However, since no standard therapy exists for EI-associated coma, and since EI is in some respects different from CHI, we suggest that HBOT may be of use to treat a coma that persists after initial therapy in the intensive care. Even delayed HBOT appears to be worthy of consideration.

Difficult airway management in the emergency room using an airway scope

In the emergency room, some cases need adequate airway management. We present a patient whom we intubated using a new device. This device might be an option in airway management but some considerations should also be taken into account.

Early morning upper airway discomfort and appearance on two X ray films

We reported a case of reversible but severe upper airway stenosis. The patient complained of only slight discomfort in her throat after waking: she had a history of allergic reaction to contrast medium. Her X ray films showed severe edema in her pharynx. Epiglottitis was diagnosed and we started treatment. It should not be forgotten, that even mild symptoms, such as discomfort in the throat, could indicate the existence of severe epiglottitis.