Hui-Bih Yuan

Bacterial Colonization of Epidural Catheters Used for Short-term Postoperative Analgesia : Microbiological Examination and Risk Factor Analysis

Background:The authors conducted this prospective study to determine the incidence, potential routes, and risk factors of microbial colonization of epidural catheter used for postoperative pain control. Methods:Two-hundred five patients with epidural analgesia for postoperative pain were studied. On removal of the catheter, five samples were sent for culture: the infusate, a swab from inside the hub of the epidural catheter connector, a swab from the skin around the catheter insertion site, the subcutaneous segment, and the tip of the catheter. Clinical data related to the catheter insertion, management, and general patient conditions were collected. Results:The positive culture rates for the subcutaneous and tip segments of the catheter were 10.5% and 12.2%, respectively. The most common organism in the culture was coagulase-negative staphylococcus. There was a strong linear relationship between bacterial colonization in the skin around the catheter insertion site and growth from the subcutaneous and tip segments of catheter (P = 0.000). Catheter-related events at ward, blood transfusion, and positive culture from the skin at the insertion site were risk factors for bacterial colonization of epidural catheters. Inflammation at catheter insertion site, catheter indwelling time, and level of catheter insertion were not predicators for epidural catheter colonization. Conclusions:The authors’ results suggest that bacterial migration along the epidural catheter track is the most common route of epidural catheter colonization. Maintaining sterile skin around the catheter insertion site will reduce colonization of the epidural catheter tip.

Fatal gas embolism as a complication of Nd-YAG laser surgery during treatment of bilateral choanal stenosis

A 40-day-old infant boy underwent Nd-YAG laser surgery because of congenital bilateral choanal stenosis. Cyanosis and cardiovascular collapse occurred during the operation. Resuscitation was initiated, but in vain; the patient died. The evolution of clinical events was consistent with a diagnosis of gas embolism. In the investigation of causes, the use of a sapphire tip with the Nd-YAG laser and the cooling of the tip with N2 gas were thought to have contributed to the fatal outcome. The authors warn of the potential risk of gas embolism with the Nd-YAG laser and a coaxial gas cooling system, and they emphasize the importance of monitoring for gas embolism in high-risk patients.

Bilateral Tension Pneumothorax and Tension Pneumoperitoneum Secondary to Tracheal Tear in a Patient With Relapsing Polychondritis

Relapsing polychondritis (RP) is a rare disease that is characterized by recurrent inflammation and destruction of cartilage and connective tissues. RP can have significant airway pathology that may require procedures to maintain airway patency and thus may have serious implications for anesthesiologists. Anesthesiologists must be prepared to deal with the possible complications that may occur during airway manipulation in patients with RP. Here, we present a case of life-threatening bilateral tension pneumothorax and tension pneumoperitoneum that developed after a tracheal tear during Montgomery T-tube insertion in a patient with tracheal stenosis due to RP. Correct diagnosis was delayed due to a misdiagnosis of airway obstruction. As a result, we emphasize that bilateral tension pneumothorax should be considered during refractory cardiac arrest in patients with increased airway pressure. A high index of suspicion and adequate management are mandatory for patients to survive these life-threatening complications.

Increased requirement for minute ventilation and negative arterial to end-tidal carbon dioxide gradient may indicate malignant hyperthermia

Characteristic signs of malignant hyperthermia (MH) include unexplained tachycardia, increased end-tidal carbon dioxide (Etco₂) concentration, metabolic and respiratory acidosis, and an increase in body temperature above 38.8°C. We present the case of a patient with highly probable MH. In addition to sinus tachycardia and metabolic and respiratory acidosis, this patient also had a negative arterial to Etco₂ gradient and an increased requirement for minute ventilation to maintain a normal Etco₂ concentration, with signs of increased CO₂ production. Despite these signs of MH, the patients rectal temperature monitoring equipment did not show an increase in temperature, although the temperature measured in the mouth was increased. This case illustrates the unreliability of measuring rectal temperature as a means of reflecting body temperature during MH and the usefulness of increased CO₂ production signs in helping to diagnose MH.

Postoperative Pulmonary Edema after Cervical Spine Surgery-A Case Report

Injury of the cervical spine may cause serious complications and neurological sequelae. Recently, a patient with C1-2 spinal cord compression developed pulmonary edema postoperatively associated with unstable hemodynamics, which might result from overzealous fluid administration in order to correct neurogenic shock during anesthesia. Therefore, early recognition and timely use of vasoconstrictors, together with judicious fluid replacement are important in the anesthetic management of patients with cervical spine injury undergoing surgery. In addition, the placement of pulmonary artery catheter is crucial for assessing the cardiac function and fluid status.

Postoperative Right Atrial and Pulmonary Embolism after Prolonged Spinal Surgery

Perioperative pulmonary thromboembolism can proceed rapidly with grave prognosis, in which immediate or accurate diagnosis and management is not easy. According to the literatures, patients receiving spinal surgery are at relatively lower risk of developing thromboembolism. We would like to present a case of postoperative pulmonary thromboembolism which developed after a prolonged lumbar spinal surgery. Tachycardia and unstable hemodynamics were noted postoperatively. Pulmonary and right atrial thrombi were disclosed by transesophageal echocardiography. Although cardiotomy and thrombectomy were immediately performed, the patient finally died 3 days after the operation. The pathogenesis of venous thromboembolism (VTE) in the surgical patients, the risk factors which predispose a patient to VTE, diagnosis, and treatment as well as the prophylactic measures of VTE are herein reviewed and discussed.

Complete atrioventricular block with bradycardia after craniotomy.

We report an 82-year-old male patient who developed complete atrioventricular block (CAVB) with severe bradycardia 1 hour after craniotomy. After emergency placement of a transvenous pacemaker, the patients heart rate was restored. Serial assays of serum cardiac enzymes, echocardiography and serum digoxin concentration did not show evidence of myocardial infarction, myocardial injury, or drug toxicity. Tracing back past history, neither syncope nor arrhythmia of any form was noted. A neurogenic heart disorder, high vagal tone, and aging possibly contributed to this cardiac event in this patient. CAVB, although uncommon, is a disastrous complication following craniotomy, and needs aggressive and instantaneous management.

Unexpected Transurethral Resection of Prostate Syndrome Complicated with Acute Myocardial Infarction during Transurethral Incision Procedure -A Case Report

Transurethral incision (TUI) is a simple and safe procedure. We, herein, present a case undergoing transurethral incision procedure during which he developed transurethral resection of prostate syndrome (TURP syndrome) and hypothermia precipitating an acute perioperative myocardial infarction attack. The potential risk of development of TURP syndrome in settings other than TURP surgery as well as its prevention are reviewed and discussed.