Authors’ reply to Grundtvig Gram et al.

European Journal of Epidemiology -     

Upper airway involvement in Parkinson’s disease resulting in postoperative respiratory failure

A 71-yr-old man with a six-year history of Parkinson’s disease (PD), Type II diabetes mellitus, myocardial infarction, and remote 20 pack-year smoking history, underwent an anterior resection of the rectum for carcinoma. Sixty hours later, the patient suffered a respiratory arrest; his antiparkinsonian medications had not been resumed. Preoperative flow-volume loops showed the characteristic saw-tooth pattern of PD indicating dysfunction of the striated muscle of the upper airway. Although postoperative respiratory distress was managed as lower airway obstruction, at the time of intubation there were no signs of lower airway pathology. Upper airway dysfunction and obstruction secondary to PD is thought to have been a contributing factor to the postoperative respiratory distress and failure. This case is presented to draw attention to the risk of upper airway dysfunction in Parkinson’s Disease, especially with the withdrawal of antiparkinsonian medications. Un homme de 71 ans souffrant d’une maladie de Parkinson depuis six ans, de diabète type II, d’un infarctus du myocarde avec une histoire de tabagisme de 20 années-paquet, subit une résection antérieure du rectum pour un cancer. Soixante heures plus tard, il fait un arrêt respiratoire avant d’avoir recommencé sa médication antiparkinsonnienne. Les courbes débits-volumes préopératoires montraient un tracé en dents de scie caractéristique du dysfonctionnement des muscles striés des voies aériennes supérieures consécutif au parkinsonnisme. Bien que cette détresse postopératoire ait été traitée comme une obstruction des voies aériennes inférieures, on n’a pas observé de signes de cette pathologie à l’intubation. On emit que le dysfonctionnement de voies aériennes supérieures a surtout contribué à la détresse et à l’insuffisance respiratoires postopératoires. Cette observation est présentée dans le but d’attirer l’attention sur le risque de dysfonctionnement des voies respiratoires causé par la maladie de Parkinson, particulièrement après l’arrêt de la médication spécifique.     

Acute ventilatory complications during laparoscopic upper abdominal surgery

Purpose

This article examines and summarizes the published reports dealing with subcutaneous emphysema, pneumothorax and carbon dioxide (CO₂) embolism during laparoscopic upper abdominal surgery. The purpose is to describe the expected clinical picture, the differential diagnosis and the management of these complications.

Source

The information was obtained from a Medline literature search and the annual meeting supplements of Anesthesiology, Anesth Analg, Br J Anaesth and Can J Anaesth.

Principal findings

An abrupt increase in PetCO₂ is the first sign of subcutaneous emphysema and of pneumothorax. Desaturation and increased airway pressure occur with pneumothorax, but not with subcutaneous emphysema alone. Desaturation and increased airway pressure also occur with bronchial intubation. The preliminary diagnosis is made by verifying the position of the tube, examination of the patient for swelling and crepitus and auscultation for air entry. Chest radiography and paracentesis confirm the diagnosis of pneumothorax, which frequently occurs with subcutaneous emphysema but is rarely of the tension type. Pulmonary embolism due to CO₂ during WAS has not been reported, but the available data suggest that small, haemodynamically inconsequential CO₂ embolism occurs without change in PetCO₂. Massive embolism is possible and will markedly decrease PetCO₂, arterial O₂ saturation (SpO₂) and blood pressure.

Conclusion

The immediate recognition of the three complications requires continuous monitoring of PetCO₂, arterial saturation, airway pressure, and an index of pulmonary compliance.     

Grafts and functional recuperation

Plasticity of undamaged projections (axonal sprouting) in the adult and neonatal mammalian spinal cord has been documented many times. It has been associated, in some paradigms, with recovery of specific functions and motor behavior. This mutually occurring recovery of function appears to be enhanced by transplants of fetal tissue.     

Patient-controlled analgesia (PCA) using fentanyl in a parturient with a platelet function abnormality

A term parturient with documented platelet dysfunction presented to the case room for induction of labour. Since this bleeding abnormality contraindicated the use of lumbar epidural analgesia (LEA), we elected to use an iv fentanyl patientcontrolled analgesia (PCA) technique for pain relief during labour. The patient received a 50 μg fentanyl loading dose after which 20 μg boluses of fentanyl were self-administered every three minutes as required. The patient received a total of 400 μg of fentanyl over the 3 1/2 hr of active labour. Mother and neonate tolerated the fentanyl without sequelae. If facilities to monitor the neonate and mother are present, this method of analgesia is useful in those patients where LEA is contraindicated. Au terme d’une grossesse, une patiente porteuse d’une dysfonction plaquettaire devait avoir une induction de travail au bloc obstétrical. Ecartant l’usage d’une epidurale à cause des risques de saignement, nous avons employé du fentanyl en autoanalgésie (PCA) pour soulager les douleurs du travail. Après une dose initiate de50 μg, la patiente s’injectait des doses de 20 μg de fentanyl iv aux 3 minutes prn. Elle utilisa un total de 400 μg de fentanyl au cours des 3,5 heures que dura le travail. La mère et le nouveau-né tolérèrent fort bien ce mode d’analgésie. L’autoanalgésie offre done une alternative au bloc épidural lorsque ce dernier est contre-indiqué toutefois, nous recommandons de monitorer la mére et le nouveau-né pendant quelques heures.     

Military discharge status of homeless veterans with mental illness

The high proportion of veterans among homeless men is perplexing given the opportunities associated with military service and the benefits long available to veterans. One little-examined risk factor for homelessness is that many homeless men may have received punitive discharges that result in ineligibility for Department of Veterans Affairs benefits. Data from a sample of homeless male veterans with mental illness enrolled in the Access to Community Care and Effective Services and Supports Program are used to examine punitive discharges as a risk factor for homelessness and to compare veterans with punitive and non-punitive discharges on premilitary, military, and postmilitary experiences. Only 7% of homeless veterans received punitive discharges. Pre-military experiences are associated with such discharges, but military experiences are not. Although a punitive discharge is a strong risk factor for subsequent homelessness, such discharges primarily reflect premilitary vulnerabilities and are a relatively minor reason for homelessness because they affect a small proportion of the general veteran population.     

Long-term neurologic and neurosensory sequelae in adult survivors of a childhood brain tumor: childhood cancer survivor study.

PURPOSE: To describe the neurologic and neurosensory deficits in children with brain tumors (BTs), compare incidence of these deficits with that of a sibling control group, and evaluate the factors associated with the development of these deficits. PATIENTS AND METHODS: Detailed questionnaires were completed on 1,607 patients diagnosed between 1970 and 1986 with a primary CNS tumor. Neurosensory and neurologic dysfunctions were assessed and results compared with those of a sibling control group. Medical records on all patients were abstracted, including radiotherapy dose and volume. RESULTS: Seventeen percent of patients developed neurosensory impairment. Relative to the sibling comparison group, patients surviving BTs were at elevated risk for hearing impairments (relative risk [RR], 17.3; P = <.0001), legal blindness in one or both eyes (RR, 14.8; P = <.0001), cataracts (RR, 11.9; P = <.0001), and double vision (RR, 8.8; P = <.0001). Radiation exposure greater than 50 Gy to the posterior fossa was associated with a higher likelihood of developing any hearing impairment. Coordination and motor control problems were reported in 49% and 26%, respectively, of survivors. Children receiving at least 50 Gy to the frontal brain regions had a moderately elevated risk for motor problems (RR, 2.0; P <.05). Seizure disorders were reported in 25% of patients, including 6.5% who had a late first occurrence. Radiation dose of 30 Gy or more to any cortical segment of the brain was associated with a two-fold elevated risk for a late seizure disorder. CONCLUSION: Children surviving BTs are at significant risk for both early and late neurologic or neurosensory sequelae. These sequelae need to be prospectively monitored.