Systemic air embolism in a patient with ingestion of a foreign body

Air embolism is defined as the entry of gas into a vascular structure. Frequently it is iatrogenic and can result in serious morbidity and mortality. We describe the case of a 59-year-old woman who presented with mediastinitis as a result of ingestion of a fishbone. Mediastinal debridement was performed which was complicated in the postoperative period by a systemic air embolism, as documented by computed tomography and clinical features.     

Systemic arterial air embolism in penetrating lung injury

Systemic arterial air embolism is frequently unrecognized as a cause of death among patients with isolated penetrating lung injury. Between 1975 and 1983 at Parkland Memorial Hospital, the complication of systemic arterial air embolism developed in 9 patients with penetrating lung injury (six gunshots and three stabbings). Eight patients were either in profound shock or experienced cardiac arrest and all were intubated and on positive-pressure ventilation, frequently on a manual resuscitator bag before or at the time of diagnosis. The diagnosis was made by direct visualization of air in the coronary vessels in all 9 patients, and in 3 air was also aspirated from the left ventricular apex and aortic root. In addition, 5 patients had clinically significant hemoptysis. At operation, only an isolated injury to the lung was found in 7 of the 9 patients. Arterial air embolism is a highly lethal complication; 6 of our patients died, a mortality rate of 66%. Thus, it clearly behooves us to be more alert to the possible occurrence of this complication among all victims of penetrating chest trauma. We must accept that systemic arterial air embolism is an established complication of penetrating lung injury and must recognize that it occurs much more frequently than has been previously reported. Prompt diagnosis coupled with aggressive efforts at cardiopulmonary resuscitation is crucial for successful management of patients with air embolism.     

Systemic air embolism during wedge resection of the lung.

IMPLICATIONS: We present a case of systemic arterial embolism during wedge resection of the lung. The importance of transesophageal echocardiographic monitoring is described.     

Massive air embolism in a Fontan patient

Most institutions performing cardiopulmonary bypass for congenital heart disease patients use an integrated hard shell cardiotomy and venous reservoir attached to an oxygenator. It is of paramount importance that the integrated reservoir be vented so as not to cause pressurization. A pressurized sealed cardiotomy has been reported to occur secondary to issues with vacuum assisted venous drainage systems as well as improper venting in general. We report a case of air embolus caused by retrograde propulsion of air through the venous line secondary to a pressurized cardiotomy reservoir in a patient with Fontan circulation. The mechanism of cardiotomy pressurization is described, and the scenario simulated in a mock circuit.     

狼疮肾炎并发肺部曲霉菌感染及脑膜炎一例暨文献复习

目的 通过报道1例典型的狼疮肾炎（LN）患者并发侵袭性真菌感染（IFI）的病例,并复习相关文献以期为临床提供早期诊治系统性红斑狼疮（SLE）患者并发IFI的依据和经验。 方法 描述患者发病及诊治经过,同时系统地回顾相关文献,分析总结SLE患者并发IFI的诊断方法、常见致病菌及易感因素。 结果 通过应用IFI诊断指南可以早期诊断SLE患者并发IFI,同时有效排除呼吸道定植等非侵袭性真菌感染,早期治疗,有利于提高该疾病的诊断率和治愈率。SLE患者并发IFI最常见的致病菌是隐球菌和曲霉菌,不是常见的白色念珠菌。SLE患者并发IFI的易感因素是狼疮活动和免疫抑制剂的应用。 结论 IFI 诊断指南对SLE并发IFI的诊断和治疗具有指导意义。SLE并发IFI的常见致病菌是隐球菌和曲霉菌,易感因素是狼疮活动和免疫抑制剂的应用。     

Rhodococcus equi pneumonia in a renal transplant patient: a case report and review of literature

Immunocompromised patients are susceptible to many pathogens, including those that are predominantly problems in veterinary medicine. We report a case of a 42-yr-old white male who presented 19 months post-cadaveric renal transplant (for IgA nephropathy) with a 5 d history of nausea, vomiting, abdominal cramping and diarrhea. Admission chest X-ray revealed a suspicious mass lesion in the left lower lobe. Computed tomography (CT) guided biopsy of the lesion showed a large zone of CD68 +ve histiocytes in a non-caseating granuloma. Gram stain revealed multiple gram-positive rods within the histiocytes, which were eventually identified as R. equi. After 4 months of therapy with fluoroquinolones (Avelox) and Azithromycin a repeat CT showed complete resolution of the lesion. We reviewed the literature with special focus on the clinical features, challenges in diagnosis, and treatment of this rare infection (especially in the transplant patients who are also on immunosuppressive therapy).     

Steroids in severe pneumonia: a literature review

Despite more than sixty years of scientific medical research, severe pneumonia, either community-acquired or nosocomial, remains a leading cause of death regardless of the patients' immunity state. The clinical introduction of new and more potent antibiotic molecules and the continuous development of efficient respiratory assistance devices may not be able to radically improve the clinical outcome of pneumonia. Adjunctive therapies based on the physiopathological mechanisms of lung damage in severe pneumonia have been strongly advocated, and corticosteroids, which present many properties that theoretically interfere with these pathways, have been widely used, with conflicting results. The aim of this review is to examine existing literature data on steroid use in severe pneumonia. Molecular, endocrinological and clinical studies will be described to help physicians to clarify the reasons for the historical debate about steroid use as an adjunctive treatment in severe pneumonia. There is growing evidence that, during lung infection, an excessive inflammatory response can have deleterious effects and contribute to tissue damage mechanisms. Because of their immunomodulatory properties, glucocorticoids have been suggested as a useful tool for regulating the complex balance of cytokine networks, and they are commonly used as an adjunctive therapy during serious infections. In severe pneumonia, preclinical data, including cytokine level detection and animal studies, have shown encouraging results, although the clinical data is controversial. Moreover, large randomized controlled trials have not been conducted to determine steroid side effects and the risk of immunosuppression-induced superinfections. The benefits of steroid use in patients with severe pneumonia have not been proven by current literature, but ongoing investigations of anti-inflammatory molecules probably represent the key point of severe infection management in the near future.     

Cerebral arterial air embolism associated with pneumothorax in a patient with pressure support ventilation

A 20-year-old woman was admitted to the ICU following a road traffic accident. She had a periorbital haematoma with a normal cerebral state on CT-scan, intrahepatic and intrasplenic haematomas and several fractures of the limb that were fixed on day 3. Twenty-four hours later, she developed a cough with symptoms of decerebration The head CT-scan showed diffuse pneumocephalus suitable with cerebral air embolism and the chest X ray a right tension pneumothorax. A chest tube was inserted. Despite the lack of hyperbaric oxygen therapy the patient recovered fully. The pneumocephalus disappeared totally after 48 hours. Seven days later, CT-scan of the head with coronal slides showed an orbital floor fracture associated with an intra-orbital aerocele.     

Two cases of fatal air embolism in children undergoing scoliosis surgery

Venous air embolism during surgery is a rare but important complication and can be rapidly fatal. We present two cases of fatal air embolism in the prone position occurring in small children undergoing surgery for progressive scoliosis.
Venous air embolism is a rare complication in the prone position. This is thought to be because in this position there is virtually no gravitational gradient between the site of surgery and the right atrium.
The possible sites of entry of air and ways that this may be minimized are discussed.     

Pulsed saline lavage causing venous air embolism in a patient with Paget's disease

Pulsed saline lavage is used to prepare bony surfaces during joint replacement surgery. A patient is described in whom a venous air embolism occurred as a result of a combination of the increased vascularity of bone seen in Paget's disease and possible air entrainment in the lavage equipment.      

Delayed derecruitment after removal of PEEP in patients with acute lung injury

Background: A step decrease in positive end-expiratory airway pressure (PEEP) is not followed by an instantaneous loss of the PEEP-induced increase in end-expiratory lung volume (EELV). Rather, the reduction of EELV is delayed, while adverse PEEP effects on hemodynamics are immediately attenuated upon the drop in airway pressure. Step PEEP increments were applied to the lungs of patients with acute lung injury. It was investigated retrospectively whether enlargement of end-expiratory lung volume and changes in lung mechanics persist 45 min after removal of the PEEP increment.
Methods: In 14 patients with acute lung injury (LIS score 2.7) EELV and volume-dependent dynamic compliance of the respiratory system (C_dyn,rs) were determined 45 min after removal of an additional PEEP increment (0.64 kPa added to baseline PEEP of 1.0 kPa).
Results: Nine patients kept an EELV gain of 13% (SD 7) and showed improved C_dyn,rs. In 5 patients, EELV was reduced (by 9% (SD 6)) and C_dyn,rs unchanged after removal of the PEEP increment compared to baseline.
Conclusion: A subgroup of patients with acute lung injury, the characteristics of which remain to be defined, benefit from prolonged recruitment effects up to 45 min after removal of a PEEP increment, while sequelae of continuously increased airway pressures are minimised.     

Pulmonary embolism following lung resection: a case report and review of the Japanese literature]

A 73-year-old male was admitted to our hospital with an abnormal shadow on a chest X-ray film. Chest CT demonstrated that a tumor shadow measuring 23 x 22 mm in size with pleural retraction was located in the right lower lobe. Transbronchial lung biopsy yielded a diagnosis of primary pulmonary adenocarcinoma. We performed a right lower lobectomy with mediastinal lymph node dissection. The patient suddenly complained of a syncope attack, tachycardia, hypotension, and hypoxemia 2 days after surgery. A perfusion lung scintigram with Tc-99 m macroaggregated albumin demonstrated localized defects at both the left lower lobe and a part of the left upper lobe. Thrombolytic and anticoagulation therapy with urokinase and heparin were immediately started. A postoperative lung scintigram 14 days after the onset of pulmonary thromboembolism showed normal filling of the left lung. The patient was discharged on the 37th postoperative day, and he has been followed up with anticoagulation therapy.     

驱动压指导PEEP滴定对机器人辅助根治性前列腺切除术老年患者呼吸功能的影响北大核心CSCD

目的观察驱动压(DP)指导呼气末正压(PEEP)滴定对机器人辅助根治性前列腺切除术(RARP)老年患者呼吸功能的影响。方法选择2020年9月至2021年9月择期全麻下行RARP的老年患者40例,年龄65~80岁,BMI 19~28 kg/m^(2),ASAⅡ或Ⅲ级。将患者随机分为两组:DP指导组(D组)和对照组(C组),每组20例。D组:机械通气后,PEEP从4 cmH_(2)O开始,以1 cmH_(2)O增幅逐渐增加,每个PEEP水平维持4 min,计算并记录4 min内最后1次呼吸循环的DP值,寻找DP最低值,此时对应的PEEP为平卧位时的最佳PEEP。屈氏体位且气腹建立后重复上述操作,滴定屈氏体位气腹下的最佳PEEP,直至手术结束。C组:以5 cmH_(2)O的固定PEEP进行机械通气。记录平卧位最佳PEEP设置完成后(C组固定PEEP通气后)4 min(T_(1))、屈氏体位气腹后滴定的最佳PEEP通气(C组改变体位与建立气腹后)1 h(T_(2))、2 h(T_(3))血气分析结果、气道峰压(Ppeak)、气道平台压(Pplat)、肺动态顺应性(Cdyn),并计算肺泡动脉氧分压差(A-aDO_(2))、氧合指数(OI)、呼吸指数(RI)、死腔/潮气量比值(V_(D)/V_(T)),记录T_(1)、T_(3)、拔管后1 min(T_(4))、术后2 h(T_(5))血清白细胞介素-6(IL-6)、白细胞介素-8(IL-8)、肿瘤坏死因子-α(TNF-α)浓度。记录术后肺部并发症(PPCs)的发生情况。结果与C组比较,D组T_(1)、T_(2)、T_(3)时PaO_(2)、Cdyn、OI明显升高(P<0.05),A-aDO_(2)、RI明显降低(P<0.05),T_(1)、T_(3)、T_(4)、T_(5)时血清IL-6、IL-8、TNF-α浓度明显降低(P<0.05)。两组术中Ppeak、Pplat、PaCO_(2)、V_(D)/V_(T)差异无统计学意义。两组均未发生PPCs。结论最小驱动压指导最佳呼气末正压设置能够改善机器人辅助根治性前列腺切除术老年患者术中呼吸功能,提高患者氧合。