Erroneous bronchial transection after video assisted thoracoscopic surgery (VATS) pulmonary resection diagnosed with bronchoscopy: Case report.

INTRODUCTION: Early recognition of VATS-related complications is crucial for early interventions, treatments and better outcomes PATIENT CONCERNS:: Patient presented with post-obstructive pneumonia like symptoms 1 week after VATS pulmonary resection. DIAGNOSIS: CT scan chest showed evidence of complete consolidation of the lobe where the pulmonary segmentectomy resection took place. INTERVENTIONS: Diagnostic bronchoscopy confirmed the erroneous transection of the Superior Segment (SS) of Right Lower Lobe (RLL). Patient was then taken back for completion lobectomy and found with necrotic SS of RLL. This finding potentially could have caused significant complication if not recognized and treated early OUTCOMES:: Patient recovered well after completion lobectomy and was discharged home several days later CONCLUSION:: Erroneous bronchial transection should be suspected early in patients presenting with post-obstructive pneumonia after VATS pulmonary resection. CT scan chest and diagnostic bronchoscopy are the 2 main diagnostic tests.

A case report of an expensive yet necessary thoracentesis: Expanding the boundaries of endoscopic ultrasound transbronchial needle aspiration.

RATIONALE: Endobronchial ultrasound has revolutionized the field of bronchoscopy and has become one of the most important tools for the diagnosis of intrathoracic lymphadenopathy and para-bronchial structures. The reach of this technique has not been limited to these structures and pleural lesions have been at times accessible. To our knowledge, pleural fluid collections have not been accessed with endobronchial ultrasound (EBUS). PATIENT CONCERNS: 52-year-old women with dyspnea, fever and a new loculated pleural effusion that was suspected to be the source of the fever but was not accessible through traditional thoracentesis. DIAGNOSIS: Malignant pleural effusion. INTERVENTIONS: Sampling and drainage of the loculated pleural fluid collection using EBUS scope introduced via the esophagus. OUTCOMES: Infection excluded. Resolution of fever and improved dyspnea after drainage of effusion. LESSONS: The convex curvilinear ultrasound bronchoscope allows unprecedented access to thoracic structures. The reach is not limited to mediastinal lymph nodes and parenchymal masses adjacent to the airways, and pleural space and pleural fluid are at times accessible, particularly when one considers the esophageal approach.

A Randomized Controlled Trial Comparing a Mapleson Circuit with Nasal Trumpet to Standard Oxygen Supplementation during EBUS Bronchoscopy under Monitored Anesthesia Care.

BACKGROUND: Endobronchial ultrasound (EBUS) procedures tend to be longer than routine bronchoscopies. Increased duration and sedative dosing put patients at increased risk for -hypoxic events. OBJECTIVE: To determine whether oxygen supplementation via a nasal trumpet connected to a Mapleson B circuit (NTM) was effective in decreasing hypoxic events when compared with the standard of care, oxygen supplementation with a nasal cannula (NC). METHODS: Patients referred for EBUS-guided transbronchial needle aspiration with monitored anesthesia care (MAC) were randomized 1:1 to NTM or to NC. Hypoxia-related procedural interruptions, the primary endpoint of the study, were documented for all patients. Patients in the NC group who had refractory desaturations were allowed to cross over to the NTM group. Secondary endpoints included: number of crossovers from NC to NTM, sedative dosing, total procedure times, whether procedure goals were achieved, complications apart from hypoxia, patient discharge status. RESULTS: Fifty-two patients were randomized to NC and 48 to NTM. Baseline characteristics were comparable. The NC group had significantly more interruptions than did the NTM group (p < 0.001). Procedure duration was also significantly (p < 0.03) shorter for the NTM group. Fourteen patients were crossed over from NC to NTM because of hypoxia. Thirteen out of the 14 completed the procedure with no interruptions. All procedures were successfully completed, and all goals were achieved. All patients returned to baseline status prior to discharge. Three minor complications of epistaxis occurred. CONCLUSION: For patients undergoing EBUS with MAC, oxygen supplementation with NTM significantly decreased the incidence of hypoxic events when compared with NC. NTM may also be of value for other subsets of patients who are at increased risk for desaturation when undergoing bronchoscopy.

Closure of a bronchopleural fistula complicating cryoprobe biopsy of the lung.

Cryoprobe biopsies are routinely performed by the interventional pulmonologist. Diagnostic yields are larger, with complication rates that are equal to or lower than that of traditional forceps biopsies. We will specifically evaluate one instance where a cryoprobe biopsy led to an alveolo-pleural fistula that did not resolve with simple tube thoracostomy. An endobronchial valve was placed and successfully resolved the pneumothorax and persistent air leak.

Outcomes of nighttime refusal of admission to the intensive care unit: The role of the intensivist in triage.

PURPOSE: To compare outcomes of patients refused medical intensive care unit (MICU) admission overnight to those refused during the day and to examine the impact of the intensivist in triage. MATERIALS AND METHODS: Retrospective, observational study of patients refused MICU admission at an urban university hospital. RESULTS: Of 294 patients, 186 (63.3%) were refused admission overnight compared to 108 (36.7%) refused during the day. Severity-of-illness by the Mortality Probability Model was similar between the two groups (P=.20). Daytime triage refusals were more likely to be staffed by an intensivist (P=.01). After risk-adjustment, daytime refusals had a lower odds of subsequent ICU admission (OR 0.46, 95% CI 0.22-0.95, P=.04) than patients triaged at night. There was no evidence for interaction between time of triage and intensivist staffing of the patient (P=.99). CONCLUSIONS: Patients refused MICU admission overnight are more likely to be later admitted to an ICU than patients refused during the day. However, the mechanism for this observation does not appear to depend on the intensivist's direct evaluation of the patient. Further investigation into the clinician-specific effects of ICU triage and identification of potentially modifiable hospital triage practices will help to improve both ICU utilization and patient safety.

Aggregatibacter aphrophilus pacemaker endocarditis: a case report.

BACKGROUND: Aggregatibacter bacteria are a rare cause of endocarditis in adults. They are part of a group of organisms known as HACEK--Haemophilus, Aggregatibacter, Cardiobacter, Eikenella, and Kingella. Among these organisms, several Haemophilus species have been reclassified under the genus Aggregatibacter. Very few cases of Aggregatibacter endocarditis in patients with pacemaker devices have been reported. CASE PRESENTATION: We present here what we believe to be the first case of Aggregatibacter aphrophilus pacemaker endocarditis. A 62-year-old African American male with a medical history significant for dual-chamber pacemaker placement in 1996 for complete heart block with subsequent lead manipulation in 2007, presented to his primary care doctor with fever, chills, night sweats, fatigue, and ten-pound weight loss over a four-month period. Physical examination revealed a new murmur and jugular venous distension which prompted initiation of antibiotics for suspicion of endocarditis. Both sets of initial blood cultures were positive for A. aphrophilus. Transesophageal echocardiogram revealed vegetations on the tricuspid valve and the right ventricular pacemaker lead (Figure 1). This case highlights the importance of identifying rare causes of endocarditis and recognizing that treatment may not differ from the standard treatment for typical presentations. The patient received intravenous ceftriaxone for his endocarditis for a total of six weeks. Upon device removal, temporary jugular venous pacing wires were placed. After two weeks of antibiotic treatment and no clinical deterioration, a new permanent pacemaker was placed and the patient was discharged home. CONCLUSIONS: This is the first case of A. aphrophilus endocarditis in a patient with a permanent pacemaker. Our patient had no obvious risk factors other than poor dentition and a history of repeated pacemaker lead manipulation. This suggests that valvulopathies secondary to repeated lead manipulation can be clinically significant factors in morbidity and mortality in this patient population.