Extravasation is one of the common complications seen with intravenous infusion. We bring forward a case of subcutaneous mannitol extravasation, which caused swelling and multiple cutaneous bullous eruptions in the hand and forearm during craniotomy. Treatment consisting of elevation of the affected extremity and application of silver sulfadiazine ointment twice daily to the injured area was successful. The possible mechanisms relevant to extravasation and its tissue damage are reviewed and discussed. Selecting proper intravenous infusion site, using pliable catheters and frequent inspection are important steps for prevention of extravasation.
Postoperative vomiting causes patients distress and delays discharge after outpatient surgery. Although P6 electroacupuncture is recognized as having an antiemetic effect, its inconvenient instrumentation may limit its clinical applicability. The purpose of this study was to explore a simple and effective alternative method for control of postoperative vomiting in outpatient surgery. We prospectively compared the effect of P6 acupoint injection with 0.2 ml 50% glucose in water (G/W) and intravenous injection of 20 μg/kg droperidol for prevention of vomiting in 120 consecutive outpatients undergoing gynecological laparoscopy with general anesthesia. Patients were randomly allocated to receive P6 acupoint injection, i.v. droperidol, or nothing as control group. Both P6 acupoint injection and i.v. droperidol 20 μg/kg were found to have a significant antiemetic effect when compared with the control group. We conclude that P6 acupoint injection with 50% G/W is a simple and effective method for reducing the incidence of postoperative emesis in outpatient surgery.
Atracheal foreign body (FB), a prosthetic tooth, was found by chance in a routine chest radiograph of a 65-yr-old male patient in the cardiovascular surgery intensive care unit on the second postoperative day. This FB, which a chest specialist using a routine bronchoscope found difficult to remove, was successfully dislodged by tracheal backflow air. Case Report A 65-yr-old male (50 kg) patient with suspected small cell carcinoma of the lung was referred to our hospital. Chest radiograph and computerized tomogram revealed multiple small nodules over both lungs and left pleural effusion. Sputum cultures and aspiration cytology for tuberculosis were negative. Because the clinical course and laboratory data did not confirm either malignancy or tuberculosis, a thoracoscopic biopsy under anesthesia was planned. Preoperative laboratory data were within normal range. Moderate restrictive ventilatory impairment was found in a pulmonary function test. A double-lumen endotracheal tube was easily inserted after induction with fentanyl 200 μg, thiopental 250 mg, and vecuronium 10 mg. Anesthesia was maintained with 1%–1.5% isoflurane in 50% oxygen-air mixture. The operation became a minithoracotomy but was performed uneventfully in 4 h. The double-lumen endotracheal tube was replaced postoperatively by a 7.5 single-lumen tube without difficulty. The patient was sent to the cardiovascular surgery intensive care unit with ventilatory support On the second postoperative day, a routine chest radiograph was taken. Surprisingly, a FB was found in front of the endotracheal tube inside the trachea (Figure 1). A chest specialist was consulted, but bronchoscopic removal of the FB with the endotracheal tube in place was difficult, because there was insufficient space to manipulate the slippery tooth. After a half hour, the specialist gave up and asked if we could remove the endotracheal tube so that he could have a bigger space to work with. However, we did not agree, because we feared that the tooth might descend further down the airway and become lodged in the opening of the main bronchus. Because a different position of the tooth was found in a repeat chest radiograph, we thought that it might be floating above the cuff of the endotracheal tube. We therefore tried to deflate the cuff and, at the same time, compressed the breathing bag forcefully hoping that a strong airflow would push the tooth back up into the mouth. We succeeded and removed the tooth (Figure 2) from the mouth with Magill forceps. The patient was tracheally extubated later. The lung biopsy confirmed the diagnosis of pulmonary tuberculosis.Figure 1: Chest radiography shows a tooth shadow at approximately the C7 level.Figure 2: The metal prosthetic tooth which was removed from trachea.Discussion We present a case of an iatrogenic FB, a piece of broken prosthetic tooth, in the trachea, which was successfully removed by simply deflating the endotracheal tube cuff and, at the same time, compressing the Ambu-bag. The deflated cuff obviously allows some expiratory air to leak and to come out through the trachea around the endotracheal tube. When such an upward air outflow is forceful enough, it will dislodge the FB upward. Air that is mechanically inflated in the lungs will find its way out only through the larynx. Conventionally, air is inflated above the larynx; such as through the endotracheal tube with an inflated cuff. In this case, air would be in and out inside the endotracheal tube. When air is given beneath the larynx, such as in transtracheal jet ventilation, in the lower part of the airway, the air moves in and out, but above the air jetting point in the trachea, there is only an unidirectional upward air outflow, the existence of which is clearly demonstrated in our previous report (1). During cardiopulmonary resuscitation with transtracheal jet ventilation, contrast medium was injected above the injecting port; migration of the barium was only observed upwardly (1). Such an air outflow can prevent aspiration of gastric contents (1–3), and it can dislodge a FB from the trachea (3). Tracheal aspiration of a FB is not unusual. Removal of a FB is necessary to free the airway and prevent infection (4–10). A bronchoscope with a rigid endoscope or with fiberoptic is usually used for removing the FB, but it is not always satisfactory, and may be incomplete (4–10). The success rate of the removal of airway FB was 92% in our hospital series (9), which is better than that of other hospitals (10). Use of other instruments adjuvant to bronchoscope, such as a suction tube (11), laparoscopic cholecystectomy biopsy forceps (12), urology baskets, and stone graspers (13), Fogarty catheters (14–15), a wire with magnetic tip (16), and yttrium-aluminum-garnet laser-assisted (17), etc., have been reported. We present another alternative to endoscopic FB removal by using air outflow from the lungs as Klain et al. (3) demonstrated in an animal study. This case shows that air outflow can dislodge a broken prosthetic tooth from the upper airway.
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