An unusual problem during central venous cannulation by Seldinger technique.
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Aged↗
Biomedical subjects
Wolfram Schummer
Publications and source records attributed to Wolfram Schummer.
Another cause of epidural catheter breakage?
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Adult↗
Toxic epidermal necrolysis after phenytoin usage in a brain trauma patient.
Toxic epidermal necrolysis is a drug-induced, rare, but life-threatening skin eruption. The main differential diagnoses are drug-induced erythema (hypersensitivity syndrome), acute graft-versus-host disease, staphylococcal scalded skin syndrome, and toxic shock syndrome. Because the therapy for toxic epidermal necrolysis and acute graft-versus-host disease differs largely from the others, it is necessary to make an accurate diagnosis. In addition to a detailed medical history, skin biopsy is mandatory because the skin eruptions are not always unequivocal. Discontinuation of the causing agent is crucial, and treatment in specialized intensive care units or burn units is supportive. Currently there is no specific treatment for toxic epidermal necrolysis. Advantages from corticosteroids, plasmapheresis, intravenous immunoglobulin, cyclophosphamide, cyclosporin, and N-acetylcysteine still remain to be established by controlled trials, or have failed to prove a benefit (thalidomide). The patient presented here demonstrates the difficulties in diagnosing toxic epidermal necrolysis in a critically ill patient. A short overview of the pathogenesis and the management of toxic epidermal necrolysis is provided.
Accidents, Traffic↗
Unrecognized internal jugular vein obstruction: cause of fatal intracranial hypertension after tracheostomy?
We report an unusual case of fatal intracranial hypertension following tracheostomy due to the obstruction of the internal jugular veins (left side: thrombosis after central venous cannulation, right side: hypoplastic vein) and their collaterals. Principal cerebral outflow through the internal jugular veins can be substituted by the internal and external vertebral vein plexus because blood drains from the brain by two major routes: the internal jugular veins and the vertebral venous plexus. We suggest transcranial color-coded duplex sonography as a simple bedside method to detect patients with significant reduction of venous drainage who are at risk of developing massive cerebral venous congestion as a result of reduced intracranial elastance.
Aged↗
Two cases of delayed diagnosis of postpartal streptococcal toxic shock syndrome.
BACKGROUND: Puerperal sepsis due to group A beta-hemolytic streptococcal (GAS) toxic shock syndrome is associated with very high morbidity and mortality. Luckily it is now rare, but diagnosis is not always easy. This report demonstrates the problem of recognizing this disease, and summarizes the current knowledge on the pathomechanism and management of streptococcal toxic shock syndrome. CASE: Two cases of postpartum streptococcal toxic shock syndrome due to GAS are described. In both cases the correct diagnosis was delayed for several days. The first patient was sent home with the diagnosis of German measles; the second patient was transferred to our neurological intensive care unit with the diagnosis of meningitis. Both patients were admitted to the intensive care unit in profound shock, both developed multiple organ failure, and one patient died. CONCLUSIONS: GAS may produce virulence factors that cause host tissue pathology. Besides aggressive modern intensive care treatment, early diagnosis and correct choice of anti-streptococcal antibiotics are crucial. A possible adverse effect of non-steroidal anti-inflammatory agents requires confirmation in a multicenter study.
APACHE↗
Persistent left superior vena cava: clinical implications for central venous cannulation.
In general, persistence of the left superior vena cava (LSVC), the most common anomaly of the venous circulation, is asymptomatic. Diagnosis of a catheter in a persistent LSVC is not straight forward, and a LSVC can create difficulties during central venous and pulmonary artery catheterization. We discuss the differential diagnosis of left-sided central venous catheters (CVC). Finally a directive is given to prevent dilator-induced vessel injuries. We report the cannulation of an unsuspected persistent LSVC in two patients. A dilator-induced vessel injury contributed significantly to the fatal outcome in the first case. On a plain chest X-ray, a catheter in a LSVC will run down the left mediastinal border and can be confused with other intravascular malpositions and extravascular malpositions. Contrast-enhanced lateral chest radiograph is an inexpensive and readily available method that can be used to determine exact position.
Journal Article↗
Case report: the malfunctioning implanted venous access device.
Totally implanted venous access devices (VADs) are an alternative to central line placement for those patients requiring frequent intravenous access. Venous thrombosis, infection, extrusion, extravasation and occlusion are commonly encountered complications of central VADS. Fracture with embolization of implantable venous access catheter is a rare complication of this commonly used device, but it may have serious consequences. Clinical manifestation may include infraclavicular or chest pain, paraesthesias in the arm, cardiac arrhythmias, palpitation or an extra heart sound, in addition to withdrawal occlusion, swelling, and resistance to infusion. Nursing staff should be aware of these signs and symptoms and they should immediately stop any infusion if these signs and symptoms emerge. Whenever problems with a VAD occur a chest radiograph or a contrast enhanced angiographic control of the VAD is advised. This article provides two cases relating to malfunction of a VAD. Despite typical symptoms in both cases a catheter fracture with embolization was not taken into consideration, and a radiological control of the VAD was not performed. It was only by chance that the patients did not sustain any harmful sequels from the broken VAD.
Adult↗