Pneumocephalus is a rare consequence of epidural anesthesia, which may occur following inadvertent or unidentified dural puncture when the loss of resistance to air technique is applied to identify the epidural space. Headache is the most common symptom presented in this condition, usually with sudden onset. This case report describes an unusual presentation of diffuse pneumocephalus after an unidentified dural puncture. The patient (male, 67 years old) was submitted to epidural catheter placement for the treatment of acute exacerbation of ischemic chronic pain using loss of resistance to air technique. No cerebrospinal fluid or blood flashback was observed after needle withdrawal. Shortly after the intervention, the patient presented symptoms of lethargy, apathy, and hypophonia, which are not commonly associated with pneumocephalus. No motor or sensory deficits were detected. Cranial computed tomography showed air in the frontal horn of the left ventricle, subarachnoid space at interhemispheric fissure and basal cisterns, confirming the diagnosis of diffuse pneumocephalus. The patient remained under vigilance with oxygen therapy and the epidural catheter left in place. After 24 hours, cranial computed tomography showed air in the temporal and frontal horns of the left ventricle, with no air in the subarachnoid space. The patient presented no neurological signs or symptoms at this time. Although headache is the most common symptom presented in reported cases of pneumocephalus, this case shows the need for the clinician to be aware of other signs and symptoms that may be indicative of this condition, in order to properly diagnose and treat these patients. Key words: Pneumocephalus, continuous epidural analgesia, ischemic chronic pain, lossof-resistance to air technique, dural puncture, headache, unusual presentation
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. carbon dioxide 30 [27][28][29][30][31][32][33][34][35] mmHg and median temperature 37.1 [36.8-37.3]°C. After removal of artefacts, the mean monitoring time was 22 h08 (8 h54). All patients had impaired cerebral autoregulation during their monitoring time. The mean IAR index was 17 (9.5) %. During H 0 H 6 and H 18 H 24 , the majority of our patients; respectively 53 and 71 % had an IAR index > 10 %. Conclusion According to our data, patients with septic shock had impaired cerebral autoregulation within the first 24 hours of their admission in the ICU. In our patients, we described a variability of distribution of impaired autoregulation according to time. ReferencesSchramm P, Klein KU, Falkenberg L, et al. Impaired cerebrovascular autoregulation in patients with severe sepsis and sepsis-associated delirium. Crit Care 2012; 16: R181. Aries MJH, Czosnyka M, Budohoski KP, et al. Continuous determination of optimal cerebral perfusion pressure in traumatic brain injury. Crit. Care Med. 2012.
Background Airway management is a commonly performed procedure in the Emergency Department (ED) and Intensive Care Unit (ICU), being tracheal intubation the gold standard with relatively high rates of complications in these settings. The purpose of our study was to analyse the airway approach in our institution at ED and ICU identifying the main complications associated and taking notice of possible factors related to them. Methods Prospective observational study conducted between May and September 2014 in the ICU and ED of Santo Antonio Hospital, with the primary aim of identifying the main complications of the airway approach in the critical patient and secondary aim to take notice of possible factors related with complications of the airway approach related to technical skills of the operator, patient´s specificities and airway approach techniques. The statistical analysis was done in cooperation with the Medical Informatics and Biostatistics Department of the Faculty of Medicine of the University of Porto. P values <0.05 were considered significant for all hypothesis testing. The analysis was done using the statistical analysis program SPSS® v.21.0 Results A total of 182 patients were included, corresponding to 257 attempted tracheal intubations (ATI). The rate of successful first-pass orotracheal intubation was 67%. Complications related to ATI were reported in 30% of all attempts, being most frequently among residents (81%, p=0.001) and those with little experience in airway approach (46%, p<0.001). The majority of complications was failed intubation (18%). In the group with complications, relation with an identifiable obvious cause was seen in 87% of cases (p<0.001), the major being inexperience in 42% of operators with complications, instead of 1% in the group without complications (p<0.001). Conclusions Failed ATI and its complications are largely dependent on operator´s expertise. Factors related to patient, lack of appropriate equipment and inappropriate strategy delineation also play a role. Recognition of patients at particular risk of difficult airway management is crucial.
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