Spontaneous Pneumothorax and Pneumomediastinum in COVID 19: Case Series

SARS COV2 infection can produce pneumothorax and spontaneous pneumomediastinum complications, which are associated with a worse prognosis. Here we present a series of cases of patients who presented subcutaneous emphysema caused by pneumothorax or spontaneous pneumomediastinum during care in the intensive care unit for pneumonia and COVID 19. This group of patients showed, in all cases, prolonged mechanical ventilation, refractory hypoxemia and hypercapnia, acute renal failure, bacterial superinfection, need for broad-spectrum antibiotics, and vasopressor support. Keywords: Subcutaneous Emphysema, Spontaneous Pneumothorax, Spontaneous Pneumomediastinum, COVID 19

Incidence and Factors that Affect Anterior Sacral Foramen Leakage in Fluoroscopically Guided Caudal Epidural Steroid Injection

Background: During the caudal epidural steroid injection (CESI), sacral foramen leakage can occur. The aim of this study was to evaluate incidence and the correlation of anterior sacral foramen leakage with several factors. Methods: We retrospectively analyzed the medical records of patients who underwent CESI. The epidural needle position and sacral foramen leakage (yes or no) in C-arm view were recorded. The following parameters were measured: 1) depth of the intervertebral disc at S1-S2, S2-S3, and S3-S4; 2) distances between the posterior borders of S1 and the apex of the sacral hiatus; and 3) depths of S1, S2 the sacral canal. Results: Ninety-one subjects were evaluated. The patients were predominately women (60%) with a mean age of 65.5 ± 11.6 years. There was leakage in 58% (53/91) of patients. One-level leakage occurred in the largest proportion of patients (27%). Age, gender, needle tip position, the depth of the intervertebral disc at S1-S2, S2-S3, and S3-S4, the distances between the posterior borders of S1 and the apex of the sacral hiatus, and the depths of S1, S2 the sacral canal were not correlated with sacral foramen leakage. Conclusion: We found leakage in 58% of patients regardless of age, gender, needle-tip position, the depth of the intervertebral disc at S1-S2, S2-S3, and S3- S4, the distances between the posterior borders of S1 and the apex of the sacral hiatus, and the depths of S1, S2 the sacral canal. Therefore, clinicians should be aware that leakage can occur in any circumstance. Keywords: incidence, factors, anterior, sacral, foramen, leakage, fluoroscopically, caudal, epidural, steroid, injection.

Elderly and Mild Brain Trauma: Future Directions for Research Studies

Keywords: Brain Trauma, Elderly Trauma, Geriatric Trauma.

Intensive Care Management of a Parturient with Glanzmann’s Thrombasthenia: A Case Report

Twenty-nine years old primigravida with a diagnosis of type 1 Glanzmann’s thrombasthenia planned for labour induction was admitted to Intensive Care Unit for close observation, pain management and correction of any anticipated bleeding.

Clinical Case: Complications after Endovascular Treatment of Intracranial Aneurysm in a Patient after Subarachnoid Hemorrhage

Intracranial aneurysm is one of the most common neurovascular complications. During the recent years the accepted treatment of enraptured cranial aneurysm is noninvasive endovascular coiling. This technique is modern but it is not without complications which can be serious and life-threatening. A clinical case of a patient admitted to the ICU of Military Medical Academy - Sofia with sub arachnoid hemorrhage is described. After a positive clinical course, the check-up magnetic resonance showed intracranial aneurism of the right carotid artery. The patient underwent angiographic endovascular treatment. Vasospasm of the middle and right brain artery and thrombosis were detected during the procedure. Attempt of thromboaspiration was made without success. This article reviews published data on broad-spectrum researches concerning complications of endovascular coiling of intracranial aneurysms and the ways to prevent and reduce them.

Critical Illness Polyneuropathy in Children with Infectious Diseases

Our goal was to establish electrophysiological features of critical illness polyneuropathy in children with infectious diseases. Materials and Methods: We evaluated peripheral nervous system involvement in 67 critically ill children, admitted in ICU with different types of infectious diseases (viral encephalitis, meningoencephalitis, meningitis, acute gastroenteritis). Age of the group varied from 4 months to 17 years. All patients underwent conduction studies and neurological investigation. Sensory and motor fibers of n. ulnaris et n. medianus, motor fibers of n. Tibialis and sensory fibers of n. Suralis were tested. Lowering of the amplitudes, conduction velocity slowing and asymmetry were accounted for the motor and sensory fibers. Results: In 47 cases (n=71) diagnosis of critical illness polyneuropathy (CIP) was established. Lesions mostly involved lower limbs nerves. According to our data, severe course of CIP was seen in 40% of all cases. Average time of CIP onset in children was 5-7 days from the beginning of mechanical ventilation. Conclusions: Critical illness polyneuropathy in children with infectious diseases is a severe condition which may lead to the disability of the patients. Average time of its onset is the 5-7 days from the beginning of the mechanical ventilation in 71% of the patients. More often sensory and motor fibers of lower limbs nerves are affected. Conduction studies is a valuable tool in diagnostic process in establishing the critical illness polyneuropathy in children with infectious diseases. Keywords: Critical illness, critical illness polyneuropathy, children, electromyography.

Ultrasound Guided Supraclavicular Block in Poland Syndrome : A Safe Alternative to General Anaesthesia

Poland syndrome is an uncommon, congenital anomaly characterized by multiple systems and organs involvement like musculoskeletal, lungs, heart, kidneys and haemopoetic system with absence of functional disability. Right sided Thorax deformity is the most common feature of this syndrome with the absence of underlying bones and muscles making this condition similar to open chest along with ipsilateral hand anomalies such as brachydactyly, syndactyly or ectodactyly [1]. The incidence of this syndrome is 1 per 30,000-50,000 live births [2]. Patients with Poland syndrome require anesthesia during surgical procedures to correct the associated deformities or the organ systems associated with the disease process. Literature shows that these patients may be more susceptible for malignant hyperthermia due to associated musculoskeletal abnormalities under general anesthesia [3]. Moreover respiratory problems and hypoxia in the perioperative period may be related to associated paradoxical breathing, lung hypoplasia and chest wall abnormalities in otherwise asymptomatic patient at rest. We report a diagnosed case of Poland syndrome presented for syndactly release Keywords: USG blocks, Supraclavicular approach.

Pediatric Corrective Spine Surgery: “The Concerns and Essentials of Anaesthetic Management”

The perioperative management of children undergoing surgical correction of spinal deformities is challenging, even in the hands of an experienced anesthesiologist. A comprehensive plan is imperative keeping in mind that the surgery is extensive, the patients have other significant organ involvement and the need for neurophysiological monitoring to assess cord function and prevent neurological deficit. Meticulous prone positioning and the application of various blood- sparing techniques are an integral part of the intraoperative management. The pre-operative status and the intra-operative events could help in predicting the need for post-operative ventilatory support. The present article aims to elucidate the importance of a streamlined evaluation, monitoring, management strategy and stratification of these patients for a favorable outcome. Keywords: Paediatric, Spine surgery, Evoked potentials.