Q: Define chylothorax and describe different treatment modalities?
Answer: Chylothorax is defined as triglycerides more than 113 mg/dl (1.24 mmol/L) in pleural cavity.
A number of therapeutic interventions have been used to reduce chyle production and promote resolution of a chylothorax. Initial management typically includes restriction or temporary cessation of enteral feedings. Enteral feedings high in medium-chain triglycerides (MCT), or parenteral nutrition may be used. Total parenteral nutrition typically results in resolution in 75 to 80% of cases by that time. In resistant cases, pleurodesis, ligation of the thoracic duct, or placement of drains and pleuroperitoneal shunts may be considered.
Octreotide has become another option for management of patients with chylothorax. Although the exact mechanism by which the drug exerts its effects has not been defined, it is believed that the multiple effects of octreotide on the gastrointestinal tract and the reduction in splanchnic blood flow reduce thoracic duct flow and decrease the triglyceride content of chyle.
Sunday, February 6, 2011
Saturday, February 5, 2011
A note on age factor for vasospasm after SAH
Age factor has always been considered in risks factors for cerebral vasospasm after the subarachnoid hemorrhage. It has been described as more common in younger patients. It is interesting to note that older people enjoy some safety from vasospasm after SAH secondary to the age-related increase in atherosclerosis, which impairs contractility and elasticity of small arteries and arterioles.
But a recent article published in "Neurosurgery" concluded that; "Age does not seem to be a significant predictor for cerebral vasospasm after subarachnoid hemorrhage".
Other risk factors for vasospasm persists which includes larger bleed in the subarachnoid space, female sex and smoking.
Age factor has always been considered in risks factors for cerebral vasospasm after the subarachnoid hemorrhage. It has been described as more common in younger patients. It is interesting to note that older people enjoy some safety from vasospasm after SAH secondary to the age-related increase in atherosclerosis, which impairs contractility and elasticity of small arteries and arterioles.
But a recent article published in "Neurosurgery" concluded that; "Age does not seem to be a significant predictor for cerebral vasospasm after subarachnoid hemorrhage".
Other risk factors for vasospasm persists which includes larger bleed in the subarachnoid space, female sex and smoking.
Patient Age and Vasospasm After Subarachnoid Hemorrhage - Neurosurgery: October 2010 - Volume 67 - Issue 4 - pp 911-917
Friday, February 4, 2011
Editors' note: Today we will take break from pearls and will publish an email from one of our regular reader. We hope someone can help him in his endeavors.
"I am an associate consultant of ICU in King Saud Medical City, lecturer of anesthesia and ICU in Cairo faculty of medicine.
I have 2 inquiries.
1- I want to go through research in stem cell transplantation in vegetative states that follow traumatic brain injury. I have proposal for this research and I want to know who can help me in this from the technical point of view. Also in ARDS patients, i m preparing same protocol. I am now in KSA, Riyadh. I have my proposal ready to email if needed.
2- I need an updated powerpoint presentation on non-invasive hemodynamic monitoring in ICU.
Thank you,
Dr.M.Samak
samakawy10@yahoo.com
"I am an associate consultant of ICU in King Saud Medical City, lecturer of anesthesia and ICU in Cairo faculty of medicine.
I have 2 inquiries.
1- I want to go through research in stem cell transplantation in vegetative states that follow traumatic brain injury. I have proposal for this research and I want to know who can help me in this from the technical point of view. Also in ARDS patients, i m preparing same protocol. I am now in KSA, Riyadh. I have my proposal ready to email if needed.
2- I need an updated powerpoint presentation on non-invasive hemodynamic monitoring in ICU.
Thank you,
Dr.M.Samak
samakawy10@yahoo.com
Thursday, February 3, 2011
Cefepime's neurotoxic effects - underestimated?
Background: Cases of cefepime neurotoxicity have been Sporadically reported in patients with renal failure. The neurotoxicity of cefepime might be underestimated and the frequency of its neurotoxic effects may be insufficiently recognized.
Methods: We retrospectively reviewed the files of patients with renal failure who were treated with cefepime and who developed neurological complications.
Results: All 8 patients developed decreased conscience, confusion, agitation, global aphasia, myoclonus, chorea-athetosis, convulsions and coma. The latency, the period between the start of treatment and neurologicaldeterioration, was 4,75 ± 2,55 days (range: 1–10 days). All patients died 17 ± 14,7 days (range: 1–42 days) after becoming symptomatic. Three of them died shortly after neurological deterioration. Five patients developed a neurological “tableau” with global aphasia. Three patients showed clinical improvement after the discontinuation of cefepime. Electroencephalography revealed diffuse slow-wave activity (delta) and triphasic sharp wave activity. These findings confirm the possible neurotoxicity of treatment with cefepime in patients with renal failure. In none of the deceased patients have we been able to directly demonstrate a causal relationship between neurotoxicity and mortality. However, when a patient treated with cefepime develops neurological deterioration or aphasia, one must be aware of cefepime's potential neurotoxicity and treatment should be stopped.
Conclusion: We recommend that, in view of the high and unexplained mortality, the use of cefepime in patients with Kidney failure should be carefully considered.
Background: Cases of cefepime neurotoxicity have been Sporadically reported in patients with renal failure. The neurotoxicity of cefepime might be underestimated and the frequency of its neurotoxic effects may be insufficiently recognized.
Methods: We retrospectively reviewed the files of patients with renal failure who were treated with cefepime and who developed neurological complications.
Results: All 8 patients developed decreased conscience, confusion, agitation, global aphasia, myoclonus, chorea-athetosis, convulsions and coma. The latency, the period between the start of treatment and neurologicaldeterioration, was 4,75 ± 2,55 days (range: 1–10 days). All patients died 17 ± 14,7 days (range: 1–42 days) after becoming symptomatic. Three of them died shortly after neurological deterioration. Five patients developed a neurological “tableau” with global aphasia. Three patients showed clinical improvement after the discontinuation of cefepime. Electroencephalography revealed diffuse slow-wave activity (delta) and triphasic sharp wave activity. These findings confirm the possible neurotoxicity of treatment with cefepime in patients with renal failure. In none of the deceased patients have we been able to directly demonstrate a causal relationship between neurotoxicity and mortality. However, when a patient treated with cefepime develops neurological deterioration or aphasia, one must be aware of cefepime's potential neurotoxicity and treatment should be stopped.
Conclusion: We recommend that, in view of the high and unexplained mortality, the use of cefepime in patients with Kidney failure should be carefully considered.
The neurotoxicity and safety of treatment with cefepime in patients with renal failure - Nephrology Dialysis Transplantation, 23, 3 Pp. 966-970.
Wednesday, February 2, 2011
Q: Propofol should be given with caution in which common allergy?
A: Egg allergy
Originally propofol was launched 32 years ago but was withdrawn from the market due to reports of anaphylactic reactions. It was re-launched in 1986 by AstraZeneca with the brand name Diprivan with preparation containing 10% soybean oil and 1.2% purified egg lecithin, a phosphatidylcholine found in egg yolk.
A history of egg allergy does not necessarily contraindicate the use of propofol. Most egg allergies are related to a reaction to the egg white (albumin) and not to the egg yolk (lecithin). This could explain why 'propofol' is only very rarely a problem. However, a patient who has an egg allergy should be carefully questioned.
A: Egg allergy
Originally propofol was launched 32 years ago but was withdrawn from the market due to reports of anaphylactic reactions. It was re-launched in 1986 by AstraZeneca with the brand name Diprivan with preparation containing 10% soybean oil and 1.2% purified egg lecithin, a phosphatidylcholine found in egg yolk.
A history of egg allergy does not necessarily contraindicate the use of propofol. Most egg allergies are related to a reaction to the egg white (albumin) and not to the egg yolk (lecithin). This could explain why 'propofol' is only very rarely a problem. However, a patient who has an egg allergy should be carefully questioned.
Tuesday, February 1, 2011
Q; What is 'Buffalo chest’?
Answer: An interpleural communication results in a single pleural space within a chest (or communicating pneumothoraces on both sides of chest) is called "Buffalo chest'.
Background: Each lung is enveloped in a pleural sac. The pleural sac consists of two serous membranes: the parietal pleura, which lines the thoracic wall, mediastinum and diaphragm; and the visceral pleura, which invests the lung. A potential space called the pleural cavity exists between the parietal and visceral pleura. A pneumothorax occurs when air fills this cavity. The two pleural sacs are separate structures therefore, a pneumothorax is unilateral, unless a communication exists between each pleural cavity.
A communication between each hemithorax can be congenital, iatrogenic or traumatic. It has been reported after procedures involving median sternotomy, laparoscopic surgery and heart and lung transplants. In surgical cases, the communication results from the disruption of the anterior pleural reflections.
An interpleural communication results in a single pleural space. This is termed ‘Buffalo chest’ because North American buffalo, or bison, lack an anatomical separation between the two hemithoraces. This facilitated death by bilateral tension pneumothoraces from a hunter's single arrow to the chest.
There should be a complete resolution of the ipsilateral and contralateral pneumothoraces via the single chest drain.
Answer: An interpleural communication results in a single pleural space within a chest (or communicating pneumothoraces on both sides of chest) is called "Buffalo chest'.
Background: Each lung is enveloped in a pleural sac. The pleural sac consists of two serous membranes: the parietal pleura, which lines the thoracic wall, mediastinum and diaphragm; and the visceral pleura, which invests the lung. A potential space called the pleural cavity exists between the parietal and visceral pleura. A pneumothorax occurs when air fills this cavity. The two pleural sacs are separate structures therefore, a pneumothorax is unilateral, unless a communication exists between each pleural cavity.
A communication between each hemithorax can be congenital, iatrogenic or traumatic. It has been reported after procedures involving median sternotomy, laparoscopic surgery and heart and lung transplants. In surgical cases, the communication results from the disruption of the anterior pleural reflections.
An interpleural communication results in a single pleural space. This is termed ‘Buffalo chest’ because North American buffalo, or bison, lack an anatomical separation between the two hemithoraces. This facilitated death by bilateral tension pneumothoraces from a hunter's single arrow to the chest.
There should be a complete resolution of the ipsilateral and contralateral pneumothoraces via the single chest drain.
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