Optimal Site for Precordial Stethoscope Placement in Pediatric Patients Younger than Two Years: A Preliminary Cross-sectional Study

Background: The precordial stethoscope is a traditional and non-invasive monitoring method during pediatric general anesthesia. In this preliminary cross-sectional study, we aimed to investigate the characteristics of lung and heart sounds via precordial stethoscope and determine the optimal site for auscultation in children below 2 years of age. Methods: This study involved 68 patients who underwent general anesthesia with tracheal intubation. Auscultation sounds via precordial stethoscope were recorded in MP3 format at the following three sites: Site A-region between the clavicle and nipple on the left midclavicular line; Site B-region between the nipple and costal arch on the left midclavicular line; and Site C-point on the left midaxillary line that was horizontally leveled with Site B. Eight blinded evaluators individually and randomly scored lung and heart sounds on a 10-point scale (0: cannot hear at all and 10: can hear clearly). Results: Lung sound scores at Sites A, B, and C were 8.0 (7.0–9.0), 4.5 (2.9–6.0), and 7.0 (5.5–8.5), respectively, while heart sound scores at Sites A, B, and C were 3.5 (2.0–6.0), 6.5 (4.0–8.0), and 1.0 (0.4–2.0), respectively. Statistically significant differences were found in all pairs of sites. Conclusion: We suggest that Site A, where anesthesiologists can hear both the lung and heart sounds, is the optimal site of precordial stethoscope attachment during general anesthesia for intubated children below 2 years of age.

SURGICAL TREATMENT OF THE NEWBORN WITH THORACOSHISIS

The article presents a case of successful surgical treatment of the newborn with a rare congenital pathology – thoracoschisis. The newborn had been transferred urgently 6 hours after birth from the perinatal center. The initial examination revealed a chest defect measuring 6×3×3 cm in size and located along the midclavicular line from the 4th to 6th ribs through which the additional lobe of the liver prolapsed (Riedel’s lobe). After examination and preoperative preparation, 17 hours after birth, a surgical treatment was carried out – moving the liver to the abdominal cavity, closing defects of the diaphragm and thorax. In the postoperative period, serous pericarditis developed, requiring puncture and pericardial drainage. On the 21st day of life the child was transferred to the somatic hospital in a satisfactory condition. Observations conducted over the two years after the operation indicated the child's satisfactory condition, and revealed no complaints. The extreme rarity of this pathology causes certain difficulties in determining the appropriate treatment strategies, and concomitant congenital malformations contribute to high mortality.

Impact of chest subcutaneous fat on the occurrence of central venous port-related infectious complications in cancer patients

Purpose There is no concrete evidence to support the association between the amount of subcutaneous fat area (SFA) in the central venous port-insertion site (precordium) and port-related complications. We aimed to investigate the relationship between SFA in the midclavicular line and postoperative infectious complications in patients undergoing port-insertion surgery. Methods This was a single-institute and historical cohort study of 174 patients who underwent first central venous port implantation surgery for chemotherapy between January 2014 and December 2018. SFA in the midclavicular line was measured using preoperative computed tomography scans. The patients were divided into three groups according to SFA amount tertiles, and we investigated the association of SFA with infectious and all-cause complication events within 1 year. Results Within a median follow-up of 306 days, the patients with intermediate SFA had significantly higher infection-free survival than those with low and high SFA (low vs. intermediate vs. high: 80.4% vs. 97.7% vs. 83.4%, respectively, p=0.034). In contrast, there was no significant difference in the overall complication-free survival among the groups (low vs. intermediate vs. high: 80.4% vs. 88.9% vs. 81.8%, respectively, p=0.29). Low SFA was independently associated with high risk of infectious complications (hazard ratio, 9.45; 95% confidence interval, 1.07–83.22, p=0.043). Conclusion Low SFA in the midclavicular line was an independent risk factor for infectious complications in the chemotherapy setting. This practical indicator can be useful for optimizing patients’ nutritional status and when considering other types of vascular access to support administration of intravenous chemotherapy.

The Abnormal and Rapid Movement of Sewing Needle From Chest Toward Heart

: We herein introduced a 3 years old girl, who is a rare case of penetrating intracardiac damage severely induced by the abnormal movement of a sewing needle form the right lung toward the heart and entering in the right ventricle, which created Right Pneumothorax and right side bleeding. In clinical examinations, all vital symptoms were normal, and there was no sign of Cardiac tamponade, except reduced sound in the right lung base. Also, the external object was retained in the midclavicular line between the third rib, which was significant. In the Simple posterior-anterior and lateral graphics of chest radio opacity linear image on the lower part of the heart, the shadow was also significant. This is a rare case of abnormal needle movement from the right thorax to the right ventricular apex, which caused pulmonary problems. Following necessary diagnostic tests, a surgery was performed to remove the needle from the patient’s chest without open-heart surgery and CPB. Finally, 3 days after the operation, the patient was discharged from the cardiac surgery service in good general condition.

Kartagener’s Syndrome: A Rare Case

Kartagener’s syndrome, an autosomal recessively inherited disorder, is a subgroup of primary ciliary dyskinesias. This genetic disorder manifests from early life which distinguishes it from acquired mucociliary disorders. Kartagener’s syndrome presents as a classical triad of situs inversus, sinusitis and bronchiectasis occurring majorly due to impaired ciliary motility. Here we report a case of a four year old female child who presented to us with repeated episodes of cough and intermittent breathlessness for the past three years. Clinical examination revealed bilateral coarse basal crepitations and apex beat on right fifth intercostal space in the midclavicular line. A thorough investigation revealed situs inversus, chronic sinusitis, and bilateral bronchiectasis. The patient underwent a high-speed video microscopy analysis which was suggestive of primary ciliary dyskinesia. Considering these findings, the patient was diagnosed as a case of Kartagener’s syndrome.

Comparison of Diaphragmatic Stretch Technique and Manual Diaphragm Release Technique on Diaphragmatic Excursion in Chronic Obstructive Pulmonary Disease: A Randomized Crossover Trial

Background. Chronic Obstructive Pulmonary Disease (COPD) impairs the function of the diaphragm by placing it at a mechanical disadvantage, shortening its operating length and changing the mechanical linkage between its various parts. This makes the diaphragm’s contraction less effective in raising and expanding the lower rib cage, thereby increasing the work of breathing and reducing the functional capacity. Aim of the Study. To compare the effects of diaphragmatic stretch and manual diaphragm release technique on diaphragmatic excursion in patients with COPD. Materials and Methods. This randomised crossover trial included 20 clinically stable patients with mild and moderate COPD classified according to the GOLD criteria. The patients were allocated to group A or group B by block randomization done by primary investigator. The information about the technique was concealed in a sealed opaque envelope and revealed to the patients only after allocation of groups. After taking the demographic data and baseline values of the outcome measures (diaphragm mobility by ultrasonography performed by an experienced radiologist and chest expansion by inch tape performed by the therapist), group A subjects underwent the diaphragmatic stretch technique and the group B subjects underwent the manual diaphragm release technique. Both the interventions were performed in 2 sets of 10 deep breaths with 1-minute interval between the sets. The two outcome variables were recorded immediately after the intervention. A wash-out period of 3 hours was maintained to neutralize the effect of given intervention. Later the patients of group A and group B were crossed over to the other group. Results. In the diaphragmatic stretch technique, there was a statistically significant improvement in the diaphragmatic excursion before and after the treatment. On the right side, p=0.00 and p=0.003 in the midclavicular line and midaxillary line. On the left side, p=0.004 and p=0.312 in the midclavicular and midaxillary line. In manual diaphragm release technique, there was a statistically significant improvement before and after the treatment. On the right side, p=0.000 and p=0.000 in the midclavicular line and midaxillary line. On the left side, p=0.002 and p=0.000 in the midclavicular line and midaxillary line. There was no statistically significant difference in diaphragmatic excursion in the comparison of the postintervention values of both techniques. Conclusion. The diaphragmatic stretch technique and manual diaphragm release technique can be safely recommended for patients with clinically stable COPD to improve diaphragmatic excursion.

Desperate times call for desperate measures

It is 5 pm on New Year’s Eve and you are on service as an emergency physician in training for the London Helicopter Emergency Medical Service (HEMS). The London Ambulance Service Control informs you of a stabbing incident in the town of Watford, England. Your helicopter arrives on the scene 10 minutes after the call and 13 minutes after the incident, along with land ambulance and police. After the scene is declared safe, you are directed to the patient, JJ, a 24-year-old male who has suffered a stabbing outside of a local bar. His friend, who made the call to EMS, tells you JJ lost consciousness about 3 minutes after the insult. The patient has no signs of life, with no palpable carotid pulse or measurable blood pressure. He is apneic and his pupils are fixed and dilated. You notice a 2-cm wound in the midclavicular line, just superior to the left nipple, consistent with a penetrating stab wound. Cardiac monitors are attached and show an initial rhythm of asystole. Closed cardiac massage is undertaken immediately with rescue breaths given using bag-valve-mask. Simultaneously, the patient is cannulated in both antecubital fossae and is administered 1 mg adrenaline with 1000 mL 0.9% saline. Emergent decompressive needle thoracotomy is performed on the left chest by placing a 14-gauge, 3.5-inch angiographic catheter into the chest cavity at the midclavicular line in the second interspace. There is no release of air but periodic bubbles and blood appear to come from the left lung. After 2 minutes of unsuccessful CPR, there is still no palpable pulse and you notice the patient’s neck veins are distended, with normal air entry and no dullness to percussion in the left hemithorax. Your helicopter is about 10 minutes away from the nearest major trauma centre.

A rare gigantic primary epithelial cyst of spleen in an adolescent boy

Cysts arising from spleen are a rare clinical entity, with their discovery usually being incidental. We present a case of the largest reported primary epithelial cyst of spleen. In present study a 16-year-old child presented with abdominal distension for 1 month associated with abdominal pain for 2 weeks. On examination, a mass was felt in the epigastrium, left hypochondrium and left flank, extending across from the right midclavicular line to the left midaxillary line, and extended inferiorly till 6cm caudal to umbilicus. CT abdomen revealed a unilocular cyst of 17x20x24cm arising from the spleen with a volume of 3700ml. Splenectomy was performed; intra-operatively there was a huge splenic cyst measuring 30x30x30cm. Histopathological examination was diagnostic of Primary congenital epithelial cyst of the spleen. Till date the largest congenital splenic cyst documented in literature is 20 cm × 13 cm × 21 cm, as reported by Valentina et al, in 2014. Present specimen bests this previous case considerably.

Laparoscopic adrenalectomy for large adrenal pheochromocytoma: a case report and discussion

A 40-year-old patient who presented hypertension and hyperglyemia, on CECT showing 7x6.2x5 cm sized retroperitoneal mass lesion in left para-aortic region extending to suprarenal region, diagnosed as pheochromocytoma. Patients BP monitored hourly, started antihypertensive and insulin. After adequate control of blood pressure and blood sugar patient planned for laparoscopic adrenalectomy by lateral transperitoneal approach. GA and combined epidural spinal anesthesia given. The patient was placed in the right-lateral decubitus position with the left side up. The surgeon and assistant stand on the right side of the table. and 4 trocars were inserted. The first port is situated 2 cm below the costal margin at the midclavicular line. The lateral port is placed under direct visualization at the anterior axillary line. The remaining port was placed between the two port. Adrenal Vein bluntly dissected, the vein is carefully doubly ligated with hemlock clips and transacted between clips. The adrenal gland was retracted in a superolateral direction and the harmonic scalpel was used to continue dissection laterally. The specimen was retrieved via a small, 4 cm incision on lateral costal margin. Histopathology of tumor specimen confirmed diagnosis as pheochromocytoma. Laparoscopy offers a better anatomical exposure, shorter length of stay, a decrease in postoperative pain, faster return to preoperative activity level, improved cosmesis, and reduced blood loss, early to resumption of oral feeding.

Features of the development of thoracic paravertebral blockade as a component of anesthesia in radical mastectomy

The aim of this work is the study of thoracic paravertebral blockade (PVB) in different anatomical parts of the chest. The usage of the PVB for 31 women was analysed. PVB was performed at the levels of Th1, Th2, Th3, Th4, Th5 and Th6, under ultrasound guidance. 1.5 ml of local anesthetic (0,75% solution of ropivacaine) was introduced on each level. The borders of altered pain sensitivity was evaluated using "pin prick" at the notional vertical lines of the chest (paravertebral, scapular, posterior axillary, mid-axillary, midclavicular and sternal). The obtained distances were measured by centimeter ruler. After blockade of spinal nerves from Th1 through Th6, the extent of the blockade of the pain sensitivity was reveded: paravertebral line at 21.7±3.9 cm, along the scapular line is a distance of 19.1±3.6 cm, on posterior axillary line of 14.5±2.6 cm, on an mid-axillary line - of 14.9±3.3 cm on the midclavicular line is 11.9±4.2 cm, sternal line - 5.4±3,3 cm. The decrease in the severity of the blockade on pain sensitivity in the midclavicular line from central to peripheral anatomical areas was observed. 71% of patients on the first day after surgery was not required additional analgesia, in 16% of cases the period of analgesia ranged from 6 to 18 hours. The decrease of the size of analgesia takeplace surface when moving from the spine to the sternum that can significantly affect the quality of anesthesia during operations on the thorax. PVB intercostal nerve Th1-Th6 with small doses of local anesthetic anesthetic is effective in ensuring operations in the amount of radical mastectomy.