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In this case report, we present a critical situation during an open calvarial reconstruction involving an 11-month-old infant. The patient experienced accidental extubation, requiring immediate intervention while in the prone position. Approximately two hours post-incision, ventilation became increasingly difficult due to a significant leak detected in the system. On closer inspection, it was observed that both the rubber tourniquet responsible for securing the anesthesia circuit and the tape that held the endotracheal tube in place had become loosened. In response to this emergency, the decision was made to remove the displaced endotracheal tube. We successfully introduced a 1.5 laryngeal mask airway (LMA; Unique™, Teleflex Incorporated, Wayne, PA), which restored ventilation. The patient maintained stable oxygen levels throughout this emergency period, displaying no signs of desaturation. An hour post-intervention, the surgical procedure was completed. The process of removing the LMA was uneventful without any complications. In the setting of emergent airway management, especially for patients in the prone position during surgical procedures, accidental extubation presents a challenge for healthcare providers. This case highlights the importance of prompt decision-making and having alternative airway devices on hand, such as an LMA.
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Cranioplasty is a common surgical procedure used to repair cranial defects, and it is associated with significant morbidity and mortality. Although frailty is a strong predictor of poor postoperative outcomes across surgical specialties, little is known about frailty's impact on cranioplasty outcomes. This study examined the association between frailty and cranioplasty by comparing the effect of the Risk Analysis Index-Administrative (RAI-A) and the Modified Frailty Index-5 (mFI-5) on cranioplasty outcomes. Methods: The National Surgical Quality Improvement Program was queried for patients undergoing cranioplasty between 2012 and 2020. Receiver operating characteristics and multivariable analyses were used to assess the relationship of postoperative outcomes and the RAI-A, mFI-5, and increasing patient age. Results: There were 2864 included study patients with a median age of 57 years (IQR, 44-67), and a higher proportion of patients were women (57.0%) and White (68.5%). The RAI-A had a more robust predictive ability for 30-day mortality (C-Statistic, 0.741; 95% confidence interval (CI), 0.678-0.804) compared with mFI-5 (C-Statistic, 0.574; 95% CI, 0.489-0.659) and increasing patient age (C-Statistic, 0.671; 95% CI, 0.610-0.732). On multivariable analyses, frailty was independently associated with mortality and other poor postoperative outcomes (P < 0.05). Conclusions: The RAI-A demonstrated superior discrimination than the mFI-5 and increasing patient age in predicting mortality. Additionally, the RAI-A showed independent associations with nonhome discharge and postoperative complications (CDII, CDIIIb, and CDIV). The high rates of operative morbidity (5.0%-36.5%) and mortality (0.4%-3.2%) after cranioplasty highlight the importance of identifying independent risk factors for poor cranioplasty outcomes.
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We present a case of a four-year-old male with a history of giant omphalocele who underwent ultrasound-guided Botox injection to bilateral anterior abdominal wall musculature in preparation for definitive repair. Botox administration was successfully combined with preoperative subfascial tissue expanders to achieve definitive midline closure of the anterior abdominal wall defect. Our experience suggests that Botox can be safely used as part of the treatment plan for giant omphalocele repair.
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Venous malformations (VMs) may manifest clinically in a broad spectrum. Most VMs are sporadic with previous studies reporting less than 1.2% to be inherited. Conversely, multifocal lesions, such as glomuvenous malformations (GVMs), which have glomus cells in their vascular walls, have been reported to have a frequency of inheritance of 63.8%. Both VMs and GVMs may occur due to sporadic mutation and must be differentiated clinically because this will dictate their proper treatment. Sporadic GVMs involve skin and subcutis, with bluish-purple coloration, are painful to compression, and have no radiographic evidence of phleboliths. Previous studies have demonstrated that VMs are almost always associated with a single lesion that is nontender to compression and are often able to be diagnosed by the presence of phleboliths on radiographic imaging. We present a case of a 14-year-old right-hand-dominant male who presented with two distinct VMs on the dorsum of the right index finger at the proximal and middle phalanges. A previously biopsied lesion overlying the ipsilateral olecranon, which was reported as a possible glomus tumor versus vascular malformation, was present as well. Based on history, physical examination, multicentric presentation, and radiographic findings, the presumptive diagnosis was that the lesions were GVMs. However, after surgical excision and histopathologic examination, the lesions were determined to be VMs because of the absence of glomus cells. Due to the difference in treatment modalities for VMs and GVMs, the ability to accurately diagnose these lesions clinically is essential. This case represents an anomalous presentation of multiple venous malformations occurring in two distinct locations in a 14-year-old boy.
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[This corrects the article DOI: 10.7759/cureus.9963.].
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The treatment of sternoclavicular joint infection is a topic of controversy. This systematic review aims to evaluate the preferred treatment of sternoclavicular joint infections. A literature search using PubMed/MEDLINE®/Embase databases was conducted to identify publications on the surgical management of sternoclavicular joint infections. Case reports and studies without surgical management were excluded. The outcomes of interest included patient demographics, comorbidities, infectious etiologies, radiographic features, surgical management, and complications. Sixteen articles met the inclusion criteria. The mean age of the subjects was 53.4 years; there was a predominance of males (65%), and a minority of the subjects were obese (15%). The most common infectious etiology was methicillin-susceptible Staphylococcus aureus (MSSA) (48%). CT scan was reported in 46% of cases. The most common treatment was surgical resection of the joints (85%), followed by muscle flap closure of the wounds (54.2%). The complication rate ranged from 0-40%. Specifically, recurrence of infection was low with resection of the joint, followed by muscle flap closure. Given the heterogeneity of the methodology and inconsistency in the outcomes, a meta-analysis could not be performed. Overall, the current literature favors the resection of the sternoclavicular joint as the gold standard treatment. Closure of the wound using muscle flap seems to adequately treat this problem without any major untoward events.
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Heterotopic Pregnancy (HP) is the simultaneous development of an intra-uterine pregnancy and ectopic pregnancy. In natural cycle, it is a very rare event. With the increasing popularity of ovulation induction performed during assisted reproductive techniques, its incidence has significantly increased. However, diagnosis is often delayed because of its rarity and difficulty. Heterotopic pregnancy is an important differential diagnosis to consider in patients with intra-uterine pregnancies presenting with acute abdominal pain and hemoperitoneum. Here we are reporting a case of heterotopic pregnancy in a 26-year-old woman presented with symptoms and signs of ruptured tubal pregnancy with live intra-uterine gestation at 8 weeks of amenorrhea.
