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We describe a patient with an intracerebral haemorrhage following an accidental dural puncture during an attempted epidural for pain relief in labour. Anaesthetists need to include intracerebral haemorrhage in the differential diagnosis of post-dural puncture headache in the puerperium.
From January 1990 to December 1993, 23 adults were hospitalized at our institution for treatment of foot infections that occurred following nail puncture wounds. All 23 patients had cellulitis, and 14 had signs of osteochondritis on a roentgenogram or a 99mTc bone scan. After undergoing surgical intervention that consisted of debridement, drainage of the pus, and exploration of the bones, patients received intravenous ciprofloxacin (400 mg b.i.d.) for 24 hours, followed by an oral regimen (750 mg b.i.d.). Nine patients with cellulitis received oral therapy for 7 days, and the 14 patients with osteochondritis received oral therapy for 14 days. Isolates that were recovered included Pseudomonas aeruginosa (18 patients) and Staphylococcus aureus (2 patients); one patient had a mixed infection, and in two cases no pathogens were recovered. All of the isolates were susceptible to ciprofloxacin. All patients were cured, and none had reinfection. Our results show that foot infection following a nail puncture wound may be treated with oral ciprofloxacin (750 mg b.i.d.) for 7-14 days, provided that surgery is performed first.
An analysis has been made on data from 576 cycles in 300 patients regarding the chances of various superovulation protocols attaining a puncture in successive cycles. The cumulative proportion of patients with at least one successful stimulation increased from 77% at the first attempt, to 98% at the fifth attempt. Of the 576 stimulations, 440 (76%) resulted in a puncture. Age, the number of ovaries and the reaction to superovulation induction contribute to the outcome of a cycle, the chances being lowest for older individuals with one ovary and an inadequate reaction in the first treatment cycle. Changing the treatment protocol did not improve the outcome in subsequent gonadotrophin-induced cycles, even if combined with clomiphene citrate. Reasons for cancellation did not tend to recur, although the incidence of dominance and premature stimulation was significantly higher in patients aged greater than 35 years. Age-dependent chances of success were calculated.
In each of 2 trials, 75 female and 75 male broilers of different sizes (large and small) were obtained from a commercial grower and were commercially processed. Breast fillets were deboned at 0.25, 1.5, 3, 6, and 24 h postmortem (total n = 15 per treatment per time point). Muscle pH and L* value were determined for each deboning time. Breast fillets were subjected to texture analysis using Allo-Kramer (10-blade), needle puncture (2 mm diameter), or razor blade shear (8.9 mm wide) methods. Allo-Kramer tests were performed on a strip (40 x 20 x 7 mm); needle puncture and razor blade shear were performed on intact muscles. Body size and sex had no effect on rigor development or color as indicated by no significant difference in breast muscle pH, R-value, or L* value. Allo-Kramer and razor blade tests exhibited significant shear value differences among samples deboned early (<1.5 h) and late (>6 h) PM. Allo-Kramer shear and razor blade tests performed similarly for differentiating breast meat of different toughness though Allo-Kramer shear force and razor blade energy were only moderately correlated (r = 0.72). Although both instrumental tests were performed in the same approximate area on each breast, it is possible that variation within the breast would have caused this marginal correlation. Although further studies would be necessary to compare the performance of both tests for assessing poultry meat toughness, the proposed razor blade test has the advantage of requiring no sample preparation (i.e., cutting a strip of constant dimensions) other than cooking.
Pseudomonas osteomyelitis following a puncture wound is commonly reported in children, but very few cases have been recorded in adults. We describe ten adult patients with well documented Pseudomonas aeruginosa osteomyelitis consequent to puncture wounds. The disease in adults is similar to that in children with respect to bone involved, clinical features, and preferred antibiotic therapy; however, the prognosis for complete recovery without permanent sequelae seems much better in adults.
This prospective study examined the efficacy of magnetic resonance imaging (MRI) in visualizing cerebrospinal fluid (CSF) leak in patients with postdural puncture headache (PDPH) and determining the spread of the blood patch in the epidural space and the extent of tamponade on the thecal sac. After obtaining institutional review board approval, five patients with symptomatic PDPH after 3 days of failed conservative treatment were included in this study. MRI using proton density (PD) and T2-weighted imaging was performed on all patients and CSF flow studies were done on one patient. All patients received 20 mL of blood in the epidural space. They remained supine for 45 min, and repeat MRI studies were performed. Extent of the spread of blood in the epidural space was measured. A visual analog scale of 0-10 was used to evaluate the headache. All patients had severe postural headache with nausea/vomiting. Preblood patch MRI showed extrathecal CSF and hemosiderosis indicating the site of dural puncture in four patients. The postprocedure MRI demonstrated the blood patch as a large extradural collection with anterior displacement of the thecal sac, the mean spread being 4.6 intervertebral spaces. The tamponade effect of the blood patch was observed on PD, T2-weighted, and CSF flow images. All patients experienced immediate resolution of their symptoms. This study suggests that using MRI, the site of the CSF leak, the tamponade effect of the blood patch, and its spread in the epidural space can be documented.
UNLABELLED: The cephalic vein of the forearm is often used for IV catheters because of its ease of access for peripheral venous cannulation. But its close relation to the sensory branch of the radial nerve sometimes causes it to be damaged when the vein is cannulated. Our anatomic study conducted on 33 specimens confirmed the risk of nerve lesion. However, it is impossible to define a safe zone, because of the randomly located nerve and vein crossing zones, where the iatrogenic risk of damaging the radial nerve is maximum. We suggest that to avoid incidents, the cephalic vein should be punctured above the emergence of the sensory branch of the radial nerve, e.g., at least 12 cm above the level of the styloid process of the radius. IMPLICATIONS: We attempted to determine the relationship between the cephalic vein and the sensory branch of the radial nerve at the wrist to help prevent lesions of the radial nerve when the cephalic vein is cannulated. We examined the anatomy of 33 postmortem specimens and suggest that puncture of the cephalic vein 12 cm or more proximal to the styloid process can prevent radial nerve lesions.
Inadvertent puncture of a tissue expander from a needle can occur both intraoperatively and postoperatively. With a small puncture hole and a partially filled expander, detection of the hole can be very difficult, especially in the postoperative period when removal of the entire device may become necessary for adequate examination. A simple method is described to detect the presence of such a leak with the use of fluorescein dye.
Postdural puncture headache is a distressing potential complication of spinal and epidural anesthesia. This article reviews the currently held thoughts on the topic, with a focus on the cause, prevention and treatment of postdural puncture headache.
OBJECTIVES: Lignans that present in the nonfat portion of sesame seed oil (SSO) can inhibit delta-5 desaturase activity, resulting in an increase in the accumulation of dihomo-gamma-linolenic acid and, subsequently, decrease the production of proinflammatory dienoic eicosanoids with a concomitant increase in the secretion of less inflammatory monoenoic eicosanoids. DESIGN: Female Balb/c mice were fed diets supplemented with 5wt% SSO or a physical mixture of oils (control) whose fatty acid composition resembled that of SSO for 3 wks. MEASUREMENTS AND MAIN RESULTS: During a 4-day observation period after cecal ligation and puncture, only 20% of the controls and as many as 65% in the SSO group survived. Furthermore, the levels of cytokines and dienoic eicosanoids produced in response to an intraperitoneal injection of a nonlethal dose (50 microg/mouse) of endotoxin were measured in both groups. The interleukin (IL)-10 levels were markedly higher in mice fed SSO diets compared with the controls. However, the plasma concentrations of prostaglandin E1 + 2, tumor necrosis factor-alpha, IL-6, and IL-12 did not differ significantly between the two groups of mice. CONCLUSIONS: Because the fatty acid composition is almost similar between the two diets, sesamin, sesamol and other lignans in SSO appear to be responsible for an increase in survival after cecal ligation and puncture and also for an increase in the IL-10 levels in response to a nonlethal dose of endotoxin in mice.
Eleven cases of deep puncture wounds of the foot and their complications are reviewed. More than half of the patients had foreign materials introduced at the time of the injury which was not completely removed initially. The morbidity with these "simple puncture wounds" may be quite prolonged. The authors conclude that attention to details when the patient is first seen in the emergency room or the physician's office and aggressive treatment of these wounds will prevent serious sequelae in many instances.
Evaluation of ten children with Pseudomonas bone and joint infections resulting from puncture wounds of the foot identified a definite pattern to sequelae. The longer the symptoms were present before adequate treatment was instituted the greater was the risk of bone and joint destruction along with the development of chronic osteomyelitis. The syndrome usually does not produce systemic signs, but the patterns is characteristic and should be considered after any puncture wound of the foot in which the symptoms worsen instead of improving with time.
Osteomyelitis of the foot caused by Pseudomonas aeruginosa has been a recognized complication of puncture wounds since 1968. This is a report of two cases, one of which had evidence that the source of the P aeruginosa was the inner sole of the footwear. Factors such as warm, moist environment, antibiotics or antiseptics directed against gram-positive flora, and serous exudates, all of which enhance the growth of P aeruginosa, should be avoided in the management of puncture wounds of the foot.
We reviewed the hospital course of 77 diabetic and 69 nondiabetic subjects who had incision, drainage, and exploration of infected puncture wounds of the foot. Diabetics were 5 times more likely to have multiple operations and 46 times more likely to have a lower extremity amputation than nondiabetics. The interval from injury to surgery was significantly longer in diabetics than nondiabetics. Total lymphocyte count and hemoglobin, hematocrit, and albumin values were significantly lower in diabetics than in nondiabetics. Diabetic amputees had higher prevalences of nonpalpable pulses, nephropathy, neuropathy, and osteomyelitis as compared with diabetic nonamputees. The neuropathic diabetic foot is not protected by pain. When combined with other comorbid factors, this may increase morbidity associated with puncture wounds of the foot.
International consensus guidelines suggest that cyclosporin should be measured in whole blood. In some instances it may be advantageous to collect capillary blood, by a finger or ear prick method. However, drug concentrations in skin-puncture blood may not necessarily correlate with those measured in venous blood. This study compared cyclosporin concentrations in blood collected from the fingertip or earlobe with blood collected by standard venipuncture. Patient preference for each of the blood collection methods was also assessed. Specimens were obtained from organ transplant patients receiving cyclosporin, using each of the three methods: venipuncture, finger prick, and earlobe prick. The samples were assayed using a specific radioimmunoassay and the results were compared. In the 102 sets of samples collected, the mean difference (+/- standard deviation) in cyclosporin concentration between finger prick and venipuncture and ear prick and venipuncture was 2.6% (+/- 9.5%) and 2.7% (+/- 12.1%), respectively, while the comparable median (IQR) differences were 1.9% (-3.4% to +6.6%) and -1.1% (-2.8% to +7.2%), respectively. A high degree of correlation was observed between finger prick and venipuncture or ear prick and venipuncture or ear prick and finger prick (r2 > 0.86). Of the three methods of blood collection, finger prick was the patients' preferred method (P < 0.01). These data suggest that capillary blood collected by skin puncture is suitable for use in cyclosporin blood monitoring and acceptable to patients.
The incidence and mortality of sepsis increase with age, consequently, 80% of the clinical mortality from sepsis occurs in patients over age 65. Despite this aged clinical population, most research models of sepsis use 6- to 16-week-old mice as patient surrogates. This age range of mice corresponds to human ages 10 to 17 years. To assess the influence of age on rodent CLP and on antibiotic therapy, we studied young (4 month), mature (12 month), and aged (24 month) mice. Male C57BL/6 mice (n = 27-30 in each age group) were subjected to cecal ligation and puncture (CLP), two punctures with a 25-gauge needle. Mice were observed untreated for 10 days. Young mice had 20% mortality, mature mice had 70% mortality (P = 0.0013 vs. young), and aged mice had 75% mortality (P = 0.0001 vs. young). To assess the effects of age on antibiotic therapy, mice were subjected to CLP as above (n = 38-40 in each age group). Mice were then randomized to treatment with intraperitoneal injections of ceftriaxone and metronidazole or normal saline. Therapy was initiated 12 h after CLP, and injections were repeated every 12 h for 7 days. Young mice saw a 56% decrease in mortality from CLP with antibiotic therapy (P = 0.001), and mature mice had a 30% decrease in mortality (P = 0.06). Aged mice saw no benefit from antibiotic therapy. We also compared plasma cytokine levels between young and aged mice after CLP. When compared with young mice, aged mice had higher levels of IL-6 and TNF-alpha 24 h after CLP. However, high IL-6 was predictive of mortality at any age. Mice appear to have age-dependent responses to intra-abdominal sepsis and to appropriate therapy.
OBJECTIVES: The purpose of this study was to examine whether anandamide, an endogenous cannabinoid receptor ligand, is involved in the pathogenesis of septic encephalopathy. DESIGN: Prospective, controlled study. SUBJECTS: Male Wistar rats (7 wks old) were randomly divided into four groups as follows: group 1, control (0.5 mL of saline injected subcutaneously); group 2, sham (surgical abdominal incision and suturing were performed, but ligation and puncture of the cecum were omitted); group 3, cecal ligation and puncture (CLP); group 4, CLP + AM 281 ([N-morpholin-4-yl]-5-[2,4-yl]-5-[2,4-dichlorophenyl]-4-methyl-1H-pyrazole-3-carboxamide) as the cannabinoid receptor antagonist (1 mg/kg intraperitoneally). INTERVENTIONS: Sepsis was induced by CLP under pentobarbital anesthesia (10 mg/kg intraperitoneally) with 1% isoflurane. A 2-Fr high-fidelity micromanometer catheter was inserted into the left ventricle via the right carotid artery to assess hemodynamics. Each of the rats was neurologically assessed at 30 mins and 12, 24, and 48 hrs after the treatment. The cytoplasmic levels of caspase-3 in the hippocampi were assayed before surgery and at 30 mins and 24 and 48 hrs after surgery using Western blotting techniques. To examine the effects of AM 281 on neurologic function and mortality rate, we set another control group treated solely with AM 281. Selective inducible nitric oxide synthase inhibitor, L-N6-(1-iminoethyl)-lysine (4 mg/kg), was injected intraperitoneally immediately after CLP to produce the CLP + L-N6-(1-iminoethyl)-lysine group to exclude the influence of depressed hemodynamics on neurologic impairment. MEASUREMENTS AND MAIN RESULTS: It was found that administration of AM 281 could prevent the hemodynamic changes induced by sepsis. Reflex responses, including the pinna, corneal, paw or tail flexion, and righting reflexes, and the escape response significantly decreased in the CLP and CLP + L-N6-(1-iminoethyl)-lysine groups at 48 hrs after the surgery. In contrast, no changes in these reflex responses were found between the CLP + AM 281 and control and sham groups. In addition, no effects of the administration of AM 281 on neurologic function and mortality rate in the control group were found. Tissue caspase-3 levels were elevated at 48 hrs after CLP in the CLP alone group (means +/- sd: control, 3.9 +/- 0.4; sham, 4.2 +/- 0.4; CLP, 7.1 +/- 1.0 [p < .01]; CLP + AM 281, 4.0 +/- 0.5 densitometric units). In addition, administration of AM 281 also decreased the mortality rate (p < .05). CONCLUSIONS: Administration of AM 281 prevented the hemodynamic changes and development of neurologic dysfunction occurring in association with septic shock, and could decrease the mortality rate in experimentally induced septic shock in rats. Although further studies are necessary to determine whether endogenous cannabinoids cause septic encephalopathy in rats directly or via their effects on systemic hemodynamics, the beneficial effects of AM 281 on these rats might have significant therapeutic implications in cases of septic encephalopathy.
A 40-yr-old woman received a series of three interlaminar epidural steroid injections for the treatment of axial neck pain secondary to degenerative disc disease. Immediately after her third injection, she experienced symptoms of a dural puncture-induced headache. This headache persisted on a daily basis for 3 mos, despite two epidural blood patches using an interlaminar approach, which was finally completely abated with a transforaminal blood patch. The headache was immediately relieved and remained alleviated through the follow-up interval of 1 yr. In this patient, a fluoroscopically guided transforaminal epidural blood patch proved to be more effective than the classic blind interlaminar approach in the treatment of post-dural puncture headache.