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Query: UMLS:C0032285 (pneumonia)
 54,520 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Increasing experience suggests that retrograde cardioplegia offers several benefits during cardiac reoperations. However, the need for dissection to allow caval snares for open coronary sinus intubation or to palpate the atrioventricular groove for transatrial coronary sinus intubation may disturb diseased vein grafts or require more dissection than necessary. Although antegrade-retrograde techniques can be used, antegrade cardioplegia risks atheromatous embolization from old vein grafts. To optimize delivery of cardioplegic solution, we designed and used "no touch" transatrial intubation of the coronary sinus for retrograde delivery of cardioplegic solution in 63 consecutive patients aged 20 to 87 years (mean 68 years) undergoing 36 redo coronary bypass operations, 7 combined redo coronary bypass/valve replacements, 6 redo aortic valve repairs/replacements, 6 redo mitral valve repairs/replacements, 4 redo double valve repairs/replacements, 2 redo triple valve repairs/replacements, and 2 redo composite aortic valve and arch replacements. "No touch" coronary sinus cannulation was achieved by minimally dissecting the aorta and high right atrium enough for two purse-string sutures. No attempt was made to dissect the junction of the inferior vena cava and atrioventricular groove if old vein grafts were present. The distal pressure line of the Gundry DLP RCSP retrograde cardioplegia cannula (DPL, Inc., Grand Rapids, Mich.) was connected to a transducer, flushed, and then introduced into the right atrium. The pressure tracing thus obtained was observed while the catheter was advanced, using its curved stylet, "blindly" without touching the heart, through the right atrium into the coronary sinus until a coronary sinus waveform was obtained (similar to floating a thermodilution catheter). The catheter's distal balloon was then inflated to occlude the coronary sinus momentarily. A rise in sinus pressure confirmed placement. If pressure did not rise, the cannula was usually in the right ventricle and was repositioned. All coronary sinuses were successfully intubated blindly. Bypass was then instituted, the aorta crossclamped, and the proximal aorta vented. Old vein grafts were cut at the aorta before retrograde cardioplegia was begun; atheromatous material was routinely flushed retrogradely from vein grafts. Only after arrest were hearts dissected as needed. Antegrade cardioplegia was not used. There were two (3%) deaths, both from hospital-acquired pneumonia, no perioperative myocardial infarctions, and no episodes of heart block. Inotropic agents were used in six of 63 patients (10%). We conclude that "no touch" transatrial retrograde cardioplegia offers optimal, simplified myocardial protection for cardiac reoperations, permits arrest of the heart before cardiac manipulations, and expands the use of retrograde cardioplegia by obviating cardiac dissection.
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PMID:Optimal delivery of cardioplegic solution for "redo" operations. 156 72

Tension pneumocephalus is a rare condition that can be a life-threatening neurosurgical emergency. It usually results from head trauma, but there have been case reports of iatrogenic causes including on non-invasive mechanical ventilation. We report a case of pneumocephalus resulting from high mechanical ventilation pressures in a patient without prior head trauma. A 37-year-old male with Duchenne's muscular dystrophy who had been ventilator-dependent through tracheostomy was admitted for shortness of breath and intermittent fevers. The patient was found to have pneumonia, with left-lower lobe consolidation, and was started on linezolid given known Methicillin-resistant Staphylococcus aureus from previous sputum culture; he was later switched to vancomycin and piperacillin-tazobactam given persistent fevers to cover for hospital-acquired pneumonia. The patient went into septic shock requiring multiple pressors as well as stress steroids for persistent shock, with eventual improvement in hemodynamics. He developed further respiratory acidosis on his usual ventilator settings, and peak inspiratory pressures (PIPs) progressively increased to as high as 45-70 cm H2O during his hospital course. PIPs did not improve with suctioning or after bronchoscopy. On the 17th day of the patient's stay, he had acutely altered mental status with non-reactive fixed and dilated pupils and disconjugate gaze of the right eye on neurologic examination. CT of the head at that time revealed extensive pneumocephalus along the bifrontal convexities, suprasellar cisterns, and posterior fossa, with a possible fracture of the frontal skull base near the ethmoid roof. Mount Fuji sign was present on CT scan, indicative of "tension pneumocephalus". Neurosurgical consultation was obtained but the family declined intervention given his overall debilitated stated. Comfort measures were instituted, and the patient expired the following day. Pneumocephalus is the accumulation of air entry into the cranial cavity, generally from head trauma, inflammation, or surgery. Patients may have underlying base skull defects or microfractures that permit air to enter the intracranial cavity. Increased sphenoid sinus pressure from mechanical ventilation may enter the subperiosteal space, allowing air to enter the intracranial cavity. It is important to consider pneumocephalus in a patient with new neurological findings after mechanical ventilation.
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PMID:Tension Pneumocephalus in a Tracheostomized, Chronically Ventilated, Duchenne's Muscular Dystrophy Patient Without Prior Head Trauma. 3306 10